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CRITERIA FOR USE:HIGH DOSE ORAL PROTON PUMP INHIBITOR
ANTONIO C. COMIA, MD
GOOD EVENING!
CRITERIA FOR USE:HIGH DOSE ORAL PROTON PUMP INHIBITOR
(THE PROMISE OF OMEPRON 40)
ANTONIO C. COMIA, MD
DOSING ISSUES
STANDARD DOSE: OMEPRAZOLE 20 MG
HIGH DOSE DOUBLE OR QUADRUPLE DOSE: 20 BID, 40 OD, 40 BID
AS INITIAL THERAPY?
IF INADEQUATE IMPROVEMENT WITH INITIAL STANDARD THERAPY?
WHEN TO GIVE HIGH DOSE PPI (OMEPRON 40) AS INITIAL THERAPY
INDICATIONS FOR HIGH DOSE PROTON PUMP INHIBITORS: DIAGNOSIS
Diagnostic trial (PPI test)
Uncomplicated GERD: no alarm symptoms
An 8-week therapeutic or empiric trial of double-dose PPI may be considered
Treatment plan should be re-evaluated if there is no response after 8 weeks.
INDICATIONS FOR HIGH DOSE PROTON PUMP INHIBITORS: GERD-RELATED COUGH
GERD-related chronic nonspecific cough
dry and non-productive cough of ≥ 3 weeks’ duration without any other respiratory symptom, sign, or systemic illness)
CHRONIC COUGH AND GERD
When GERD is the cause of chronic cough there may be no GI symptoms – silent GERD
24 hour esophageal pH monitoring provides a sensitive and specific test for the presence of GERD
GERD related cough may take 2 – 3 months to resolve with therapy
Definitive diagnosis of cough resulting from GERD can only be made if the cough resolves with anti-GERD therapy
CHRONIC COUGH AND GERD
Accurate diagnosis and therapy of chronic cough due to GERD is difficult
Therapeutic, empiric trial with PPI is reasonable initial diagnostic approach
Non-response does not rule out GERD as cause of chronic cough
Objective investigations for GERD are suggested (esophageal pH monitoring)
Laryngopharyngeal reflux (LPR)
Hoarseness, throat pain, dysphagia, throat clearing, dyspnea, chronic cough
May not have the classic symptoms of GERD
Also called silent reflux.
Cause: LES dysfunction, acid reflux upwards to throat
PPI TEST: useful in diagnosis and treatment Double dose, given at east 8 weeks
INDICATIONS FOR HIGH DOSE PROTON PUMP INHIBITORS AS INITIAL THERAPY Gastric Ulcers – may give Omeprazole 40 mg as initial
dose, specially in high risk NSAID patients
Pathologic hypersecretory conditions (e.g., Zollinger-Ellison syndrome) – up to 240 mg/day
Helicobacter pylori eradication to reduce recurrence of duodenal ulcers, as part of dual or triple antibiotic-based therapy – given together with antibiotics Double-dose PPI therapy, typically for 1–2 weeks
INDICATIONS FOR HIGH DOSE PROTON PUMP INHIBITORS:
Endoscopic evidence of severe erosive esophagitis presence of ulceration, stricture, perforation, or bleeding Presence of Barrett’s
Double-dose PPI as initial therapy
May continue with double dose as maintenance therapy.
Treatment and maintenance doses for severe reflux esophagitis
Relapse rates during maintenance of severe reflux esophagitis
17.5% for healing doses (high dose PPI)
29.1% for half-healing doses (standard dose PPI)
Double dose (OMEPRON 40 MG) for healing and maintenance
HIGH DOSE PPI IN ULCER REBLEEDING
Acid suppression with PPI use significantly reduces the risk of re-bleeding in bleeding peptic ulcers.
The mechanism of action is thought to be related to clot stabilization by increasing gastric pH.
Both oral and intravenous PPIs have been demonstrated to decrease hospital stay, re-bleeding rate and the need for blood transfusion in patients treated with endoscopic therapy.
INDICATIONS FOR HIGH DOSE PROTON PUMP INHIBITORS:
Prevention of acute rebleeding of peptic ulcers after endoscopic hemostasis
IV PPI initially for 72 hours: 80 MG LD, 8 MG PER HOUR
Quadruple-dose oral PPI may be given in 2 divided doses for 5 days
Standard doses should be used thereafter.
INDICATIONS FOR HIGH DOSE PROTON PUMP INHIBITORS:
Reduction of risk of upper gastrointestinal bleeding in critically ill patients (STRESS BLEEDING)
who have documented intolerance, contraindication, or insufficient response to intravenous H2RA therapy
Double-dose PPI for up to 2 weeks
WHEN TO GIVE HIGH DOSE PPI:
INADEQUATE IMPROVEMENT WITH STANDARD THERAPY
REASONS FOR LACK OF RESPONSE WRONG DIAGNOSIS – MALIGNANCY, NOT ACID-
RELATED (GALLSTONES, PANCREATIC DISEASE, COLONIC) – PPI WILL NOT WORK
PATIENT COMPLIANCE, TIMING OF MEDICATIONS
GERD NOCTURNAL ACID BREAKTHROUGH ESOPHAGEAL AND GASTRIC MOTILITY DISORDERS LES DYSFUNCTION
REASONS FOR LACK OF RESPONSE
BARRETT’S AND LPR – INADEQUATE RESPONSE
PEPTIC ULCERS – CONTINUED ASPIRIN/NSAID USE
RESISTANCE? TOLERANCE?
INDICATIONS FOR HIGH DOSE PROTON PUMP INHIBITORS Insufficient improvement in OR recurrence of symptoms
of GERD or other acid-related disorders (such as high-risk NSAID-related gastric ulcers)
after an adequate trial (≥ 4 to 8 weeks) of standard-dose PPI
Double-dose PPI (for ≥ 4 weeks) may be started empirically without further diagnostic testing
INDICATIONS FOR HIGH DOSE PROTON PUMP INHIBITORS:
Insufficient improvement in or recurrence of symptoms of GERD or other acid-related disorders (such as high-risk NSAID-related gastric ulcers) after an adequate trial (≥ 4 to 8 weeks) of double-dose PPI therapy
Higher than double-dose PPI therapy may be started while awaiting further consultation and testing, and continued as maintenance therapy
INDICATIONS FOR HIGH DOSE PROTON PUMP INHIBITORS:
Step-down: titrate according to symptom control.
If test results suggest possible relative “resistance” to that particular PPI, then consider switching to another PPI at double the standard dose.
SUMMARY:Selected Indications for High-Dose PPI (OMEPRON 40)
Diagnostic PPI Test for Uncomplicated GERD, and Non-cardiac Chest Pain
GERD-related chronic cough
Empiric diagnosis and treatment of LPR
Selected Indications for High-Dose PPI (OMEPRON 40)
Treatment and maintenance of severe reflux esophagitis
Prevention of rebleeding of peptic ulcers
THANK YOU!