Presentation on theme: "Journal club M Mujahid Khan 09/05/2013. GERD Literature review Critical appraisal."— Presentation transcript:
Journal club M Mujahid Khan 09/05/2013
GERD Literature review Critical appraisal
Physiological gastroesophageal reflux (GER) is the passage of gastric contents into the esophagus and occurs up 2/3 of normal infants; and, it resolves spontaneously around 9-12 months of age. Gac Med Mex. 2011;147 Suppl 1:51-6.Gac Med Mex. [Gastroesophageal reflux disease].
When GER causes symptoms or complications is considered gastroesophageal reflux disease (GERD) and it is associated to growth impairment, anemia, apnea, wheezing or other chronic respiratory symptoms, asthma, recurrent pneumonia or sleeping problems.
The pathophysiology of GERD is multifactorial and is associated with three potential abnormalities in LES motility: incompetence of the LES; inadequate gastric emptying; and delayed gastric emptying.
Proposed mechanisms of GERD-induced asthma include a vagally mediated reflex, heightened bronchial reactivity, microaspiration, and immune system modification. The Relationship Between GERD and AsthmaKristi M. Issac, BS, PharmD, AE- Pharmacist. 2009;34(7):30-35.
The diagnosis of GERD can be confirmed by esophageal biopsy via upper gastrointestinal tract endoscopy, esophageal manometry, intraluminal impedance monitoring, 24-h esophageal pH monitoring, or intraluminal impedance monitoring combined with 24-h esophageal pH monitoring. Jornal Brasileiro de Pneumologia J. bras. pneumol. vol.37 no.5 São Paulo Sept./Oct. 2011
Two recent systematic reviews indicated that the prevalence of GERD symptoms is substantially higher in adults and children with asthma than in those without. The prevalence of GER diagnosed by pH monitoring was 51%. In another review, which included 20 studies of children with asthma, the mean age- adjusted prevalence of GERD was 22.8%. Gastroesophageal reflux disease and airway hyperresponsiveness: concomitance beyond the realm of chance?* J. bras. pneumol. vol.37 no.5 São Paulo Sept./Oct. 2011*
20 articles that described 5706 patients, (1966 through December 2008). The average prevalence of GERD was 22.0% in asthma cases and 4.8% in controls. The conclusion was that there is a possible association between GERD and asthma in paediatric patients seen with asthma in referral settings. However, because of methodologic limitations of existing studies, the paucity of population-based studies, and a lack of longitudinal studies, several aspects of this association are unclear. Pediatrics Apr;125(4):e doi: /peds Epub 2010 Mar 29. Pediatrics. Gastroesophageal reflux and asthma in children: a systematic review. Thakkar K, Boatright RO, Gilger MA, El-Serag HB.Thakkar KBoatright ROGilger MAEl-Serag HB
Prevalence studies have not produced sufficient evidence to determine whether the relationship between asthma and GERD is incidental or causal. Even longitudinal studies have been unable to answer this question. Gastroesophageal reflux disease and airway hyperresponsiveness: concomitance beyond the realm of chance?* J. bras. pneumol. vol.37 no.5 São Paulo Sept./Oct *
In conclusion, there are very few methodologically sound studies in this field with paediatric cases, and more double-blind randomized controlled trials are necessary to decide whether we should use PPI in children with concomitant asthma and GERD. JInvestig Allergol Clin Immunol. 2009;19(1):1-5.Investig Allergol Clin Immunol. Does treatment with proton pump inhibitors for gastroesophageal reflux disease (GERD) improve asthma symptoms in children with asthma and GERD? A systematic review. Sopo SM, Radzik D, Calvani MSopo SMRadzik DCalvani M
Lansoprozole for children with difficult asthma JAMA American Lung association Asthma Clinical Research Centre
Clinical question Patients :6- 17 years of age children with difficult asthma Intervention: lansoprozole Comparison: placebo Outcome: Improvement in AQL
Is the trial valid? What are the results? Will the results help locally?
Did the study ask a clearly focused question. Yes Can’t tell No
Was this a randomised controlled trial (RCT) and was it appropriately so? Yes Can’t tell No
Were participants appropriately allocated to intervention and control groups? Yes Can’t tell No
4. Were participants, staff and study personnel ‘blind’ to participants’ study group? Yes Can’t Tell No
Were all of the participants who entered the trial accounted for at its conclusion? Yes Can’t Tell No
Were the participants in all groups followed up and data collected in the same way? Yes Can’t Tell No
Did the study have enough participants to minimise the play of chance? Yes Can’t Tell No
How are the results presented and what is the main result?
Results High prevalence of GERD in asthma. No statistically significant difference in primary or secondary outcome. In the subgroup with positive pH study no treatment effect of lansoprozole is observed. Children treated reported more respiratory infection.
How precise are these results?
Were all important outcomes considered so the results can be applied? Yes Can’t Tell No
To date, a precise mechanism link between gastro- oesophageal reflux and decline in asthma control has not been established. The results of trials of anti-reflux therapy are often disappointing,especially in older children, but an empirical trial is reasonable in younger children if the history is suggestive. An update on paediatric asthma -Gunilla Hedlin, Jon Konradsen and Andrew Bush. Eur Respir Rev -Sept 2012