Journal club M Mujahid Khan 09/05/2013. GERD Literature review Critical appraisal.

Journal club

M Mujahid Khan

09052013

bull GERDbull Literature reviewbull Critical appraisal

bull Physiological gastroesophageal reflux (GER) is the passage of gastric contents into the esophagus and occurs up 23 of normal infants and it resolves spontaneously around 9-12 months of age

Gac Med Mex 2011147 Suppl 151-6 [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

bull 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 200934(7)30-35

bull 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 vol37 no5 Satildeo Paulo SeptOct 2011

Literature review

bull Two recent systematic reviews indicated that the prevalence of GERD symptoms is substantially higher in adults and children with asthma than in those without

bull 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 228

Gastroesophageal reflux disease and airway hyperresponsiveness concomitance beyond the realm of chance J bras pneumol vol37

no5 Satildeo Paulo SeptOct 2011

bull 20 articles that described 5706 patients (1966 through December 2008)

bull The average prevalence of GERD was 220 in asthma cases and 48 in controls

bull The conclusion was that there is a possible association between GERD and asthma in paediatric patients seen with asthma in referral settings

bull 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 2010 Apr125(4)e925-30 doi 101542peds2009-2382 Epub 2010 Mar 29

Gastroesophageal reflux and asthma in children a systematic review Thakkar K Boatright RO Gilger MA El-Serag HB

bull Prevalence studies have not produced sufficient evidence to determine whether the relationship between asthma and GERD is incidental or causal

bull 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 vol37 no5 Satildeo Paulo SeptOct 2011

bull 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 200919(1)1-5

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 M

Critical Appraisal

Lansoprozole for children with difficult asthma

JAMA

American Lung association Asthma Clinical

Research Centre

Clinical questionbull Patients 6- 17 years of age children with difficult asthmabull Intervention lansoprozolebull Comparison placebo bull Outcome Improvement in AQL

bull Is the trial valid bull What are the results bull Will the results help locally

bull Did the study ask a clearly focused question

1048713 Yes 1048713 Canrsquot tell 1048713 No

bull Was this a randomised controlled trial (RCT) and was it appropriately so

Yes 1048713 Canrsquot tell 1048713 No

Were participants appropriately allocated to intervention and control groups

Yes 1048713 Canrsquot tell 1048713 No

4 Were participants staff and study personnel lsquoblindrsquo to participantsrsquo study group

Yes Canrsquot Tell No

Were all of the participants who entered the trial accounted for at its conclusion

Yes Canrsquot Tell No

Date of download 552013Copyright copy 2012 American Medical Association

All rights reserved

From Lansoprazole for Children With Poorly Controlled Asthma A Randomized Controlled Trial

JAMA 2012307(4)373-380 doi101001jama20112035

Figure Legend

bull Were the participants in all groups followed up and data collected in the same way

Yes Canrsquot Tell No

bull Did the study have enough participants to minimise the play of chance

Yes Canrsquot Tell No

bull How are the results presented and what is the main result

Results

bull High prevalence of GERD in asthmabull No statistically significant difference in primary or

secondary outcomebull In the subgroup with positive pH study no treatment

effect of lansoprozole is observed bull Children treated reported more respiratory infection

bull How precise are these results

bull Were all important outcomes considered so the results can be applied

Yes Canrsquot Tell No

bull To date a precise mechanism link between gastro-oesophageal reflux and decline in asthma control has not been established

bull 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

THANK YOU