Tratamentul hiperaciditatii gastrice

20 Septembrie 2012

Ilie-Damboiu Dan

Clase
IPP Antagonisti H2 Antiacide Protectoare mucoasa: Sucralfat, Subsalicilat de bismut Prostaglandine Anticolinergice (-) Analogi somatostatina (Octreotid)

BRGE / Gastrita

BRGE/ Gastrita
A Recomandari ig - diet B Antiacide : -utilizate des (la 2ore) - efic : Al + Mg (IR doar Al) - restrictie sodiu preparate adaptate C Blocanti de receptor H2 -Brge usor-mediu -nu suprima secretia acida total Cimetidina (-) 300 mg x 24/zi sau 400-800 2/zi inainte de masa de SEARA Ranitidina 150-300 mg la 12 ore Famotidina 20-40 mg seara Nizatidina 150-300 mg la 12 ore E Mucoprotectoare : Bismut D IPP (efecte adv scazute ; frecevent 1 linie) : F Antiacid de bariera : omeprazol 20-40 mg 1/zi lansoprazol 15-30 mg 1/zi - Alginat sodiu (! Reflux alcalin, rabeprazol 20 mg 1/zi gravide) pantoprazol 40mg 1/zi esomeprazol 20-40mg 1/zi omeprazol bicarbonat sodiu (Zegerid) 40 mg 1/zi

 Prokinetice : metoclopramid, domperidona, trimebutina Chirurgical (simpt severa, rebela la trat) : - fundoplicatura (Nissen)

Masuri igieno-dietetice
IPP minim 2 luni (2- 3luni) ; + BRGE intretinere termen lung Prokinetice ( metoclopramid, motilium, trimebutina) +/- bismut, alginat de sodiu

Ulcer gastric/duodenal

Care sunt cauzele UGD - 1

1.Helicobacter Pylori (H. pylori) Majoritatea ulcerelor au la baza infectia cu HP ! Totusi, nu toti cei infectati cu HP fac si ulcer H. pylori POATE avea ca efect slabirea mecanismelor de aparare ale mucoasei, permitand dezvoltarea unui ulcer secundar agresiunii acide

Care sunt cauzele UGD - 2

2. AINS Utilizarea indelungata blocheaza COX si scade secretia de PG
3. Gastrinom (Syndrom Zollinger-Ellison) Tumora de duoden sau pancreas ce secreta cantitati +++ de gastrina -> + secretia acida

4. Ulcere de stres Rezultate in urma traumei fizice (ex : arsuri cutanate grave)

Helicobacter pylori

Gram negativ, forma de spirala, cu flageli

Barry Marshall, M.D. 1983 ; 2005

Percentages of Population Infected with H. pylori

www.helico.com

Helicobacter pylori
-Ureaza (uree amoniac + CO2) -Teste depistare : Non-endoscopice : -Ig G seric valoare scazuta (infectie/vindecare ) -Test respirator cu uree(C13/C14) CO2 aer expirat Sb si Sp 95 % - Test antigen fecal (Stop IPP 2sapt inainte + 24 h BRH2 + 4sapt fara AB) - Test genetic - identificare ADN HP rezistent la antibioticoterapie standard + forme cu virulenta crescuta Endoscopice : -biopsie + test cu uree si indicator culoare pH - pozitiv +/- lame MO ; -cultura + AB grama ( lipsa facilitati ; cercetare)

Testare ADN HP :

-genotipuri virulenta +++ : ce contin gena cagA

- genotipuri cu rezistenta la tratamentul antibiotic standard (domain V of the 23S rRNA gene or the rdxA gene )

! Rolul H. Pylori in boala ulceroasa

Reactivitatea gazdei la infectia cu H. Pylori determina rezultatul infectiei : Gastrita BRGE UG/D Cancer gastric ( x3-6 ; adk gastr, limfom MALT)

 UGD Tratament 1. Igieno-dietetic: Dieta alimentar mult mai lax dup introducerea antisectetoriilor moderne Evitarea alimentelor acide, iui, piprate Nu cafea n plin puseu ulceros Interzicerea fumatului s-a demonstrat endoscopic c fumatul ntrzie vindecarea ulcerului Interzicerea consumului de: Aspirin Antiinflamatorii nesteroidiene Corticoizi

UGD Tratament 2. Medicamentos: b. Protectoare ale mucoasei gastrice n UG se poate aduga Sucralfat 4g/zi, n 4 prize - sucroz polisulfatat de aluminiu - leag srurile biliare i pepsina i - stimuleaz secreia de prostaglandine c. Antiacide la ora actual rar folosite Reduc simptomele dureroase Neutralizeaz excesul de acid Medicaie simptomatic: - Maalox -Almagel Blocanii H2: - Ranitidin 300 mg/zi - Famotidin (Quamatel) 40 mg/zi - Nizatidin (Axid) 300 mg/zi

Eradicare Hp
Terapie combinata Terapie duala(IPP + amoxi /IPP + claritro) ineficienta Tripla terapie (7-10zile) : PPI x2/zi + amoxi 1g ( x2/zi) + claritro 500mg ( x2/zi) ! Claritro absorbtie favorizata de acid. crescuta Alergie la peniciline : inloc cu Metronidazol 500mg (2/zi) Noua tripla terapie (7 zile) : Levofloxacina 500 mg (1/zi) sau 250 mg x2/zi + amoxi 1g x2/zi + IPP x2/zi Qvadrupla terapie (esec) (10-14 zile) : Metronidazol 500 mg x4/zi + Tetracilcina 500mg x 4/zi + Bismut 1g x 4/zi + IPP x 2/zi ( alternativa noua : bismuth subsalicylate/metronidazole/tetracycline - oral, Helidac 3cp + PPI x 2/zi) (European HP study group) Intretinere IPP 4saptamani sau m mult Control EDS 6-8 saptmani + testare HP

Noua tripla terapie

esomeprazole 40mg x2 + levofloxacin 500mg + amoxicillin 1000 mg x2(96%)
or esomeprazole 40mg x2 + levofloxacin 500mg + clarithromycin 500mg x2 (93%) for seven days is very effective and safe for H. pylori eradication.

 IPP(U ac) : omeprazol 40 mg 2/zi lansoprazol 15-30 mg 2/zi rabeprazol 20 mg 2/zi pantoprazol 40mg 2/zi esomeprazol 40mg 2/zi

Efecte adverse

IPP bine tolerat; Hiper gastrinemie Ameteli eruptii tegumentare

Reactii adverse Antagonisti H2 :

-durere de cap, diaree, ameteala, oboseala, confuzie ; tahifilaxie(inj) - cimetidina efect antiadrogenic (ginecomastie)

 From The American Journal of Gastroenterology Clostridium difficile-associated Diarrhea and Proton Pump Inhibitor Therapy A Meta-analysis Sailajah Janarthanan MD; Ivo Ditah MD; M Phil; Douglas G Adler MD; Murray N Ehrinpreis MD Authors and Disclosures Posted: 08/23/2012; Am J Gastroenterol. 2012;107(7):10011010. 2012 Nature Publishing Group

Ulcer de stress
Dg : Sangerare G-I > EDS Tratament : PREVENTIA ATI chirugie : masurare la fiec ora a aciditatii gastrice tinta pH > 4 Eficienta maxima IPP(eso,pantoprazol) pe injectomat (0.03 ml/min) Risc : ventilati, MODS, istoric ulcer sau HDS Cu sangerare constituita IPP iv tinta pH > 5

Interaciuni medicamentoase

ASA + IPP = risc crescut de evenimente aterotrombotice

EXPERT CONSENSUS DOCUMENT

ACCF/ACG/AHA 2010 Expert Consensus Document on the Concomitant Use of Proton Pump Inhibitors and Thienopyridines: A Focused Update of the ACCF/ACG/AHA 2008 Expert Consensus Document on Reducing the Gastrointestinal Risks of Antiplatelet Therapy and NSAID Use

J Am Coll Cardiol, doi:10.1016/j.jacc.2010.09.010 (Published online 8 November 2010) 2010 by the American College of Cardiology Foundation
This article has been co-published in the American Journal of Gastroenterology and Circulation.

Conclusions
Among patients receiving aspirin and clopidogrel, prophylactic use of a PPI reduced the rate of upper gastrointestinal bleeding. There was no apparent cardiovascular interaction between clopidogrel and omeprazole, but our results do not rule out a clinically meaningful difference in cardiovascular events due to use of a PPI.

(Funded by Cogentus NCT00557921.)

Pharmaceuticals;

ClinicalTrials.gov

number,

Deepak L. Bhatt, M.D., M.P.H., Byron L. Cryer, M.D., Charles F. Contant, Ph.D., Marc Cohen, M.D., Angel Lanas, M.D., D.Sc., Thomas J. Schnitzer, M.D., Ph.D., Thomas L. Shook, M.D., Pablo Lapuerta, M.D., Mark A. Goldsmith, M.D., Ph.D., Loren Laine, M.D., Benjamin M. Scirica, M.D., M.P.H., Sabina A. Murphy, M.P.H., and Christopher P. Cannon, M.D. for the COGENT Investigators N Engl J Med 2010; 363:1909-1917November 11, 2010

TESTE PENTRU TERAPIE PERSONALIZATA

Situatii speciale

Alternative sigure AINS

Varstnici ! -Paracetamol -Algocalmin -Cox 2 selectiv/specific (relativ!) -AINS + IPP - luate separat - gata combinate ( naproxen + esomeprazol) Vimovo

- pacient ce necesita antiagregare plachetara + FR ( ASA + esomeprazol) - Axanum

- AINS + preventie ulcer (varstnici) Misoprostol - 200 microgr x 4/zi (doza citoprotectie / scadere aciditate) ; ef adv : crampe abd, diaree, NU femei perioada fertila ,dc nu folos contraceptie)

IPP(Omeprazol) + sarcina -Probabil ca este sigur ( 2cazuri malfor cardiace in 1500 pac) - doar Omeprazol -nu in timpul alaptarii - pe prim plan : masuri ig-diet + medicamente mai vechi, mai sigure (Alginat)

Concluzii
BRH2 si mai ales IPP au revolutionat tratamentul hiperaciditatii (- ch) Nu IPP / BRH2 pana nu excludem posibila neoplazie gastrica ( 0.1 1%) IPP injectabil ( ulcer stress, sangerari acute, risc mare de sangerare, ATI ) Prudenta admin AINS pacienti la risc (tarati, ATI, varstnici.. Prefera alternative sau administrare cu protectie gastrica (IPP) IPP (doza unica dimineata; ulcer ac 2/zi 1-0-1 ) BRH2 adminstrat seara Rezistenta HP cautare terapii AB noi

Cazuri
A 29-year-old man presents with intermittent epigastric discomfort, without weight loss or evidence of gastrointestinal bleeding. He reports no use of aspirin or nonsteroidal antiinflammatory drugs (NSAIDs). Abdominal examination reveals epigastric tenderness. A serologic test for Helicobacter pylori is positive, and he receives a 10-day course of triple therapy (omeprazole, amoxicillin, and clarithromycin). Six weeks later, he returns with the same symptoms. How should his case be further evaluated and managed?

A 53-year-old man, who is otherwise healthy and has a 20-year history of occasional heartburn, reports having had worsening heartburn for the past 12 months, with daily symptoms that disturb his sleep. He reports having had no dysphagia, gastrointestinal bleeding, or weight loss and in fact has recently gained 20 lb (9 kg). What would you advise regarding his evaluation and treatment?

Gravida luna 5 pirozis, disconfort abdominal tratament : a. Antagonisti H2 b. IPP omeprazol c. IPP(nexium) d. Masuri igienico-dietetice e. IPP + Sucralfat f. Cerem eval EDS g. Tripla terapie h. Alginat

Cimetidine, an H2 antagonist, is effective at reducing acid but has several side effects EXCEPT : a. Inhibition of drugs metabolized by CYP450s b. An antiandrogen effect c. Can result in hypergastrinemia d. Can cause confusion and disorientation in the elderly

The three major pathways regulating parietal cell acid secretion include:
a. Vagal nerve stimulation b.Endocrine stimulation via gastrin c. Paracrine stimulation via histamine d. 1 an 2 e. All of the above

Va multumesc pentru atentie !