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Jaworek AJ, Carroll TL. Chronic Cough and Pulmonary Manifestations of Laryngopharyngeal Reflux Disease. Otolaryngol Clin North Am 2025; 58:485-496. [PMID: 40148169 DOI: 10.1016/j.otc.2025.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2025]
Abstract
Laryngopharyngeal reflux plays an important role in respiratory diseases such as chronic cough, asthma, chronic obstructive pulmonary disease, interstitial lung disease, and lung transplantation, among others. In cases of refractory chronic cough, reflux testing (hypopharyngeal-esophageal multichannel intraluminal impedance with dual-PH sensor and high-resolution esophageal manometry) will assist the clinician in determining whether additional reflux treatment steps should be undertaken. It is important to consider all mechanisms of reflux pathophysiology to yield the optimal result in the management of a patient with chronic respiratory disease.
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Affiliation(s)
- Aaron J Jaworek
- St. Luke's University Health Network and Specialty Physician Associates, Bethlehem, PA, USA
| | - Thomas L Carroll
- Division of Otolaryngology-Head and Neck Surgery, Brigham and Women's Hospital, Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, MA, USA.
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2
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Singh A, Khanna R, Suman A, Pollack J, Sekhsaria S. The relationship of gastroesophageal reflux disease and asthma control. Eur Clin Respir J 2024; 11:2348267. [PMID: 38741665 PMCID: PMC11089934 DOI: 10.1080/20018525.2024.2348267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 04/23/2024] [Indexed: 05/16/2024] Open
Abstract
Purpose To study whether ACT responses are confounded by gastro-esophageal status (GERD), and if this is in concordance with the variation in Forced Expiratory Volume in 1 second (FEV1%) and Fractional Excretion of Nitric Oxide (FeNO). Materials and Methods This is a prospective cohort study (n = 307). Patients were surveyed for demographics data, and underwent ACT scoring, FEV1% and FeNO testing. Results Patients with GERD had mean ACT scores that were 4.1 (p < .001) lower than without-GERD group. Not-well-controlled asthmatics (FEV1% <80, high FeNO) with-GERD had mean ACT scores that were 2.9 (p < .001) for FEV1% <80 and 3.8 (p = .008) for high FeNO lower than without-GERD group respectively. Well-controlled asthmatics (FEV1% ≥80, low FeNO) with-GERD had mean ACT scores that were 5.2 (p < .001) for FEV1% ≥80 and 5.1 (p < .001) for low FeNO lower than without-GERD group respectively. Conclusion Our study demonstrates that symptoms of GERD can lead to an inaccurate perception of asthma control and ACT as compared to objective measures, such as FEV1% and FeNO. Hence, this can lead to mismanagement of asthma, especially when objective measures are not conducted along with ACT.
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Affiliation(s)
- Arzoe Singh
- College of Arts and Sciences, University of Virginia, Charlottesville, VA, USA
| | - Rahul Khanna
- Division of Allergy & Immunology, Medstar Union Memorial Hospital, Baltimore, MD, USA
| | - Annya Suman
- Jacobs School of Medicine and Biomedical Sciences, University of Buffalo, Buffalo, NY, USA
| | - Jack Pollack
- Division of Allergy & Immunology, Medstar Union Memorial Hospital, Baltimore, MD, USA
| | - Sudhir Sekhsaria
- Division of Allergy & Immunology, Medstar Union Memorial Hospital, Baltimore, MD, USA
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3
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Fangxu L, Wenbin L, Pan Z, Dan C, Xi W, Xue X, Jihua S, Qingfeng L, Le X, Songbai Z. Chinese expert consensus on diagnosis and management of gastroesophageal reflux disease in the elderly (2023). Aging Med (Milton) 2024; 7:143-157. [PMID: 38725699 PMCID: PMC11077342 DOI: 10.1002/agm2.12293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 02/01/2024] [Accepted: 02/02/2024] [Indexed: 05/12/2024] Open
Abstract
Gastroesophageal reflux disease (GERD) in the elderly is characterized by atypical symptoms, relatively severe esophageal injury, and more complications, and when GERD is treated, it is also necessary to fully consider the general health condition of the elderly patients. This consensus summarized the epidemiology, pathogenesis, clinical manifestations, and diagnosis and treatment characteristics of GERD in the elderly, and provided relevant recommendations, providing guidance for medical personnel to correctly understand and standardize the diagnosis and treatment of GERD in the elderly.
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Affiliation(s)
- Liu Fangxu
- Department of Gastroenterology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric MedicineChinese Academy of Medical SciencesBeijingChina
| | - Li Wenbin
- Department of Gastroenterology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric MedicineChinese Academy of Medical SciencesBeijingChina
| | - Zhang Pan
- Department of Gastroenterology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric MedicineChinese Academy of Medical SciencesBeijingChina
| | - Chen Dan
- Department of Gastroenterology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric MedicineChinese Academy of Medical SciencesBeijingChina
| | - Wu Xi
- Department of Gastroenterology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric MedicineChinese Academy of Medical SciencesBeijingChina
| | - Xu Xue
- Department of Gastroenterology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric MedicineChinese Academy of Medical SciencesBeijingChina
| | - Shi Jihua
- Department of Gastroenterology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric MedicineChinese Academy of Medical SciencesBeijingChina
| | - Luo Qingfeng
- Department of Gastroenterology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric MedicineChinese Academy of Medical SciencesBeijingChina
| | - Xu Le
- Department of Gastroenterology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric MedicineChinese Academy of Medical SciencesBeijingChina
| | - Zheng Songbai
- Department of GeriatricsHuadong Hospital Affiliated to Fudan UniversityShanghaiChina
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4
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Cosío BG, Shafiek H, Mosteiro M, Iglesias A, Gómez C, Toledo-Pons N, Martinez R, Lopez M, Escribano Gimeno I, Pérez de Llano L. Redefining the Role of Bronchoscopy in the Workup of Severe Uncontrolled Asthma in the Era of Biologics: A Prospective Study. Chest 2023; 164:837-845. [PMID: 36921895 DOI: 10.1016/j.chest.2023.03.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 02/19/2023] [Accepted: 03/08/2023] [Indexed: 03/14/2023] Open
Abstract
BACKGROUND Severe uncontrolled asthma (SUA) is frequently treated with biologic therapy if a T2 phenotype is found. Bronchoscopy is not routinely recommended in these patients unless a specific indication to rule out comorbidities is present. RESEARCH QUESTION Is routine bronchoscopy safe and useful in phenotyping and endotyping patients with SUA before the indication of a biologic therapy? STUDY DESIGN AND METHODS Prospective study of consecutive patients with SUA who were referred to a specialized asthma clinic to assess the indication of a biologic therapy. Patients were clinically phenotyped as T2-allergic, T2-eosinophilic, and non-T2. All patients underwent bronchoscopy, and systematic data collection of endoscopic findings, microbiology of bronchial aspirate, and presence of eosinophils in bronchial biopsy were recorded and compared between asthma phenotypes. Cluster analysis was performed accordingly. RESULTS One hundred patients were recruited and classified as T2-allergic (28%), T2-eosinophilic (64%), and non-T2 (8%). On bronchoscopy, signs of gastroesophageal reflux disease were detected in 21%, vocal cord dysfunction in 5%, and tracheal abnormalities in 3%. Bronchial aspirate culture isolated bacteria in 27% of patients and fungi in 14%. Three clusters were identified: nonspecific, upper airway, and infection, the latter being less frequently associated with submucosal eosinophilia. Eosinophils were detected in 91% of bronchial biopsies. Despite a correlation to blood eosinophils, five patients with T2-phenotypes showed no eosinophils in bronchial biopsy, and three patients with non-T2 showed eosinophils in bronchial biopsy. Only one patient had moderate bleeding. INTERPRETATION Routine bronchoscopy in SUA eligible for biologic therapy is a safe procedure that can help to better phenotype and personalize asthma management.
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Affiliation(s)
- Borja G Cosío
- Department of Respiratory Medicine, Hospital Universitario Son Espases. Palma de Mallorca, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III (CIBERES), Madrid, Spain; Health Research Institute of the Balearic Islands (IdISBa), University Hospital Son Espases, Palma, Spain.
| | - Hanaa Shafiek
- Department of Chest Diseases, Faculty of Medicine, University of Alexandria, Egypt
| | - Mar Mosteiro
- Department of Respiratory Medicine, Hospital Alvaro Cunqueiro, Vigo, Spain
| | - Amanda Iglesias
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III (CIBERES), Madrid, Spain; Health Research Institute of the Balearic Islands (IdISBa), University Hospital Son Espases, Palma, Spain
| | - Cristina Gómez
- Health Research Institute of the Balearic Islands (IdISBa), University Hospital Son Espases, Palma, Spain; Department of Pathology, Hospital Universitario Son Espases, Palma de Mallorca, Spain
| | - Nuria Toledo-Pons
- Department of Respiratory Medicine, Hospital Universitario Son Espases. Palma de Mallorca, Spain; Health Research Institute of the Balearic Islands (IdISBa), University Hospital Son Espases, Palma, Spain
| | - Rocio Martinez
- Department of Respiratory Medicine, Hospital Universitario Son Espases. Palma de Mallorca, Spain; Health Research Institute of the Balearic Islands (IdISBa), University Hospital Son Espases, Palma, Spain
| | - Meritxell Lopez
- Department of Respiratory Medicine, Hospital Universitario Son Espases. Palma de Mallorca, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III (CIBERES), Madrid, Spain; Health Research Institute of the Balearic Islands (IdISBa), University Hospital Son Espases, Palma, Spain
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Emilsson ÖI, Aspelund T, Janson C, Benediktsdottir B, Juliusson S, Maislin G, Pack AI, Keenan BT, Gislason T. Positive airway pressure treatment affects respiratory symptoms and gastro-oesophageal reflux: the Icelandic Sleep Apnea Cohort Study. ERJ Open Res 2023; 9:00387-2023. [PMID: 37817868 PMCID: PMC10561083 DOI: 10.1183/23120541.00387-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 07/24/2023] [Indexed: 10/12/2023] Open
Abstract
Aim To study the effect of positive airway pressure (PAP) treatment on nocturnal gastro-oesophageal reflux (nGOR) and respiratory symptoms among clinical obstructive sleep apnoea (OSA) patients. Methods 822 patients newly diagnosed with OSA referred for PAP treatment were recruited. 732 patients had a 2-year follow-up visit with continuous PAP compliance data (366 full PAP users, 366 partial/non-PAP users). They answered questionnaires, including reporting of nGOR, sleep and respiratory symptoms and general health. Patients with nGOR symptoms once a week or more were defined as "with nGOR". Those without nGOR symptoms and nGOR medication were defined as "no nGOR". Others were defined as "possible nGOR". Results At 2-year follow-up, PAP treatment among full users resulted in decreased nGOR (adjusted OR 0.58, 95% CI 0.40-0.86) and wheezing (adjusted OR 0.56, 95% CI 0.35-0.88) compared with partial/non-PAP users. Decreased nGOR, among both full and partial/non-users of PAP treatment, was associated with a decrease in productive morning cough (adjusted OR 4.70, 95% CI 2.22-9.99) and a decrease in chronic bronchitis (adjusted OR 3.86, 95% CI 1.74-8.58), but not decreased wheezing (adjusted OR 0.90, 95% CI 0.39-2.08). A mediation analysis found that PAP treatment directly led to a decrease in wheezing, not mediated through nGOR. Conversely, PAP treatment decreased productive cough mediated through a decrease in nGOR. Conclusion In an unselected group of OSA patients, PAP treatment for 2 years was associated with a decrease in nGOR and respiratory symptoms. The PAP treatment itself was associated with less wheezing. A decrease in nGOR through PAP treatment was associated with a decrease in productive cough.
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Affiliation(s)
- Össur Ingi Emilsson
- Department of Sleep, Landspitali – The National University Hospital of Iceland, Reykjavik, Iceland
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
- Department of Medical Sciences: Respiratory Medicine and Allergology, Uppsala University, Uppsala, Sweden
| | - Thor Aspelund
- Centre for Public Health Sciences, University of Iceland, Reykjavik, Iceland
| | - Christer Janson
- Department of Medical Sciences: Respiratory Medicine and Allergology, Uppsala University, Uppsala, Sweden
| | - Bryndis Benediktsdottir
- Department of Sleep, Landspitali – The National University Hospital of Iceland, Reykjavik, Iceland
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Sigurdur Juliusson
- Department of Otolaryngology, Landspitali – The National University Hospital of Iceland, Reykjavik, Iceland
| | - Greg Maislin
- Division of Sleep Medicine/Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Allan I. Pack
- Division of Sleep Medicine/Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Brendan T. Keenan
- Division of Sleep Medicine/Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Thorarinn Gislason
- Department of Sleep, Landspitali – The National University Hospital of Iceland, Reykjavik, Iceland
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
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Oh TY, Hofmekler T, Freeman AJ. Update in Pediatric Gastroenterology and Nutrition. UPDATE IN PEDIATRICS 2023:369-398. [DOI: 10.1007/978-3-031-41542-5_15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Optimal follow-up period after switching to another inhaled corticosteroid/long-acting β2 agonist in patients with asthma: A retrospective study using Japanese administrative claims data. PLoS One 2022; 17:e0276001. [PMID: 36227895 PMCID: PMC9560144 DOI: 10.1371/journal.pone.0276001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 09/27/2022] [Indexed: 11/07/2022] Open
Abstract
Switching inhalation devices is a reasonable option if problems with control, adherence, or inhalation technique occur in patients with asthma treated with inhaled corticosteroid (ICS)/long-acting β2 agonist (LABA). However, evidence to determine the extent to which the carefully monitored period persists after switching is insufficient. In this study, we aimed to investigate the duration of the carefully monitored period after switching to another ICS/LABA. This retrospective study used claims data from Japanese health insurance associations from May 2014 to April 2019. A total of 1,951 patients who switched to another ICS/LABA during the study period were selected for analysis. The relative risk of the first exacerbation after switching was calculated for each four-week interval after the switch compared with that before the switch in a self-controlled case series design. We further assessed patient background associated with exacerbations during the follow-up period. In the primary analysis, the risk of asthma exacerbation compared to the control period was derived from a conditional logistic regression model, which showed a significant decrease immediately after the switch (1 to 4 weeks, Odds ratio [OR] 0.37, 95% confidence interval [CI] 0.26–0.54). Subsequently, the risk increased again and was not significantly different from the control period until week 32 (OR 0.55, 95% CI 0.29–1.04). In a sensitivity analysis among patients with a history of exacerbations, up to week 20 was the period of no continuous risk reduction (OR 0.84, 95% CI 0.41–1.70). In the secondary analysis, chronic rhinosinusitis, sleep disorders, and a history of asthma exacerbation were significantly associated with asthma exacerbation. The incidence of exacerbation remained high for approximately 4 to 7 months after patients with asthma switched to another ICS/LABA. Therefore, these patients should be carefully monitored for at least 4 to 7 months and should be re-assessed at an earlier point in time, if necessary.
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8
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Pepsin and the Lung—Exploring the Relationship between Micro-Aspiration and Respiratory Manifestations of Gastroesophageal Reflux Disease. J Pers Med 2022; 12:jpm12081296. [PMID: 36013245 PMCID: PMC9410290 DOI: 10.3390/jpm12081296] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 08/03/2022] [Accepted: 08/04/2022] [Indexed: 11/16/2022] Open
Abstract
Gastroesophageal reflux disease (GERD) is one of the most commonly encountered disorders in clinical practice nowadays, with an increasing burden on healthcare systems worldwide. GERD-related respiratory symptoms such as unexplained chronic cough, bronchial asthma or chronic obstructive pulmonary disease (COPD) with frequent exacerbations often pose diagnostic and therapeutic challenges and may require a multidisciplinary approach. Moreover, a potential role of GERD as a risk factor has been proposed for chronic rejection in patients who underwent lung transplantation. Pepsin has gained considerable attention from the scientific community in the last few years as a possible surrogate biomarker for GERD. The aim of this narrative review was to provide an overview of the potential utility of pepsin detection as a marker of micro-aspiration in various biological fluids retrieved from patients with suspected GERD-induced respiratory manifestations and in lung transplant patients with allograft dysfunction. Data on the subject remains highly contradictory, and while certain studies support its applicability in investigating atypical GERD manifestations, at the moment, it would be realistic to accept a modest utility at best. A major lack of consensus persists regarding topics such as the optimal timeframe for fluid collection and cut-off values. Further research is warranted in order to address these issues.
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Andrenacci B, Ferrante G, Roberto G, Piacentini G, La Grutta S, Marseglia GL, Licari A. Challenges in uncontrolled asthma in pediatrics: important considerations for the clinician. Expert Rev Clin Immunol 2022; 18:807-821. [PMID: 35730635 DOI: 10.1080/1744666x.2022.2093187] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 06/20/2022] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Despite symptoms control being the primary focus of asthma management according to guidelines, uncontrolled asthma is still an issue worldwide, leading to huge costs and asthma deaths at all ages. In childhood, poor asthma control can be even more harmful, as it can irreversibly compromise the children's lung function and the whole family's well-being. AREAS COVERED Given the problem extent, this review aims to discuss the leading modifiable causes of uncontrolled asthma in Pediatrics, giving some practical insights regarding the critical role of families and the main tools for monitoring control and drug adherence, even at a distance. The most recent GINA documents were used as the primary reference, along with the latest evidence regarding the management of asthma control and the impact of the COVID-19 pandemic on asthma. EXPERT OPINION In managing pediatric asthma, a multidisciplinary, multi-determinant, personalized approach is needed, actively involving families, schools, and other specialists. In addition to current strategies for implementing control, electronic health strategies, new validated asthma control tools, and the identification of novel inflammatory biomarkers could lead to increasingly tailored therapies with greater effectiveness in reaching asthma control.
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Affiliation(s)
- Beatrice Andrenacci
- Pediatric Unit, Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Giuliana Ferrante
- Department of Surgical Sciences, Dentistry, Gynaecology and Paediatrics, Pediatric Division, University of Verona, Verona, Italy
| | - Giulia Roberto
- Pediatric Unit, Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Giorgio Piacentini
- Department of Surgical Sciences, Dentistry, Gynaecology and Paediatrics, Pediatric Division, University of Verona, Verona, Italy
| | - Stefania La Grutta
- Institute of Translational Pharmacology, National Research Council, Palermo, Italy
| | - Gian Luigi Marseglia
- Pediatric Unit, Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Amelia Licari
- Pediatric Unit, Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
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Lin TK, Tsai CF, Huang JY, Pan LF, Jong GP. Exposure to Proton Pump Inhibitors and the Risk of Incident Asthma in Patients with Coronary Artery Diseases: A Population-Based Cohort Study. J Pers Med 2022; 12:824. [PMID: 35629246 PMCID: PMC9146427 DOI: 10.3390/jpm12050824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 05/12/2022] [Accepted: 05/17/2022] [Indexed: 12/10/2022] Open
Abstract
We aimed to determine the association between proton pump inhibitor (PPI) use and incident asthma in patients with coronary artery disease (CAD). This nationwide cohort study collected claims data from the Taiwanese Bureau of National Health Insurance from 2004 to 2013. The primary outcome, i.e., the risk of incident asthma, was assessed by estimating hazard ratios (HRs) and 95% confidence intervals (CIs). The adjusted HR of asthma development was estimated using the Cox regression model. Sensitivity and subgroup analyses were also conducted. A total of 8894 PPI users and 12,684 H2-receptor antagonist (H2RA) users were included in patients with CAD. Compared with H2RA use, an increased risk of incident asthma was found between PPI use and the risk of incident asthma in patients with CAD after adjusting for sex, age, urbanization, and low income (HR: 1.41; 95% CI: 1.04-1.89). The sensitivity analysis results were consistent with the main analysis results. However, the subgroup analysis revealed no association of incident asthma in patients with diabetes mellitus, hyperlipidemia, stroke, allergic rhinitis, pneumonia, cancer, or depression in the PPI group compared with those in the H2RA group. In conclusion, PPI use increased the risk of asthma development in patients with CAD.
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Affiliation(s)
- Tsung-Kun Lin
- Department of Pharmacy, Taoyuan Armed Forces General Hospital, Taoyuan 32551, Taiwan;
- School of Pharmacy, National Defense Medical Center, Taipei 11490, Taiwan
| | - Chin-Feng Tsai
- Division of Cardiology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung 40201, Taiwan;
- School of Medicine and Institute of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan;
| | - Jing-Yang Huang
- School of Medicine and Institute of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan;
- Department of Medical Research, Chung Shan Medical University Hospital, Taichung 40201, Taiwan
| | - Lung-Fa Pan
- Graduate Institute of Radiological Science, Central Taiwan University of Science and Technology, Taichung 40653, Taiwan;
- Department of Cardiology, Taichung Armed Forces General Hospital, Taichung 41168, Taiwan
| | - Gwo-Ping Jong
- Division of Cardiology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung 40201, Taiwan;
- School of Medicine and Institute of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan;
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11
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Grandes XA, Talanki Manjunatha R, Habib S, Sangaraju SL, Yepez D. Gastroesophageal Reflux Disease and Asthma: A Narrative Review. Cureus 2022; 14:e24917. [PMID: 35706753 PMCID: PMC9187188 DOI: 10.7759/cureus.24917] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2022] [Indexed: 11/05/2022] Open
Abstract
Gastroesophageal reflux disease (GERD) is defined by retrograde reflux of gastric contents to the esophagus leading to various signs and symptoms that range from heartburn/regurgitation to the development of extraesophageal respiratory syndromes like asthma. Although a cause-effect relationship has been proposed, evidence suggests that these two entities share a complex mechanism that may be reciprocal to each other. The understanding of the underlying mechanisms is imperial due to the fact that asthmatic patients may benefit from reflux therapy with subsequent improvement in pulmonary function testing and quality of life. This study has revised available literature in order to provide evidence for a nexus between GERD and asthma based on clinical correlation, pathophysiology, and pharmacologic management.
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12
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Abstract
The aim of this review is to explore the relationship between esophageal syndromes and pulmonary diseases considering the most recent data available. Prior studies have shown a close relationship between lung diseases such as asthma, chronic obstructive pulmonary disorders (COPD), Idiopathic pulmonary fibrosis (IPF), and lung transplant rejection and esophageal dysfunction. Although the association has long been demonstrated, the exact relationship remains unclear. Clinical experience has shown a bidirectional relationship where esophageal disease may influence the outcomes of pulmonary disease and vice versa. The impact of esophageal dysfunction on pulmonary disorders may also be related to 2 different mechanisms: the reflux pathway leading to microaspiration and the reflex pathway triggering vagally mediated airway reactions. The aim of this review is to further explore these relationships and pathophysiologic mechanisms. Specifically, we discuss the proposed hypotheses for the relationship between the 2 diseases, as well as the pathophysiology and new developments in clinical management.
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Ananth S, Navarra A, Vancheeswaran R. Obese, non-eosinophilic asthma: frequent exacerbators in a real-world setting. J Asthma 2021; 59:2267-2275. [PMID: 34669527 DOI: 10.1080/02770903.2021.1996598] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE In the UK, asthma deaths are at their highest level this century. Increased recognition of at-risk patients is needed. This study phenotyped frequent asthma exacerbators and used machine learning to predict frequent exacerbators. METHODS Patients admitted to a district general hospital with an asthma exacerbation between 1st March 2018 and 1st March 2020 were included. Patients were organized into two groups: "Infrequent Exacerbators" (1 admission in the previous 12 months) and "Frequent Exacerbators" (≥2 admissions in the previous 12 months). Patient data were retrospectively collected from hospital and primary care records. Machine learning models were used to predict frequent exacerbators. RESULTS 200 patients admitted for asthma exacerbations were randomly selected (73% female; mean age 47.8 years). Peripheral eosinophilia was uncommon in either group (21% vs 19%). More frequent exacerbators were being treated with high-dose ICS than infrequent exacerbators (46.5% vs 23.2%; P < 0.001), and frequent exacerbators used more SABA inhalers (10.9 vs 7.40; P = 0.01) in the year preceding the current admission. BMI was raised in both groups (34.2 vs 30.9). Logistic regression was the most accurate machine learning model for predicting frequent exacerbators (AUC = 0.80). CONCLUSIONS Patients admitted for asthma are predominately female, obese and non-eosinophilic. Patients who require multiple admissions per year have poorer asthma control at baseline. Machine learning algorithms can predict frequent exacerbators using clinical data available in primary care. Instead of simply increasing the dose of corticosteroids, multidisciplinary management targeting Th2-low inflammation should be considered for these patients.
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Affiliation(s)
- Sachin Ananth
- West Hertfordshire Hospitals NHS Trust, Watford, Hertfordshire, UK
| | - Alessio Navarra
- West Hertfordshire Hospitals NHS Trust, Watford, Hertfordshire, UK
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14
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Zheng Z, Luo Y, Li J, Gao J. Randomised trials of proton pump inhibitors for gastro-oesophageal reflux disease in patients with asthma: an updated systematic review and meta-analysis. BMJ Open 2021; 11:e043860. [PMID: 34376437 PMCID: PMC8356177 DOI: 10.1136/bmjopen-2020-043860] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE Asthma often coexists with gastro-oesophageal reflux disease (GERD). The effect of proton pump inhibitors (PPIs) treatment on asthma concomitant with GERD was inconsistent. This study aimed to assess whether PPIs treatment improved morning peak expiratory flow (mPEF) in asthma patients with GERD. DATA SOURCES PubMed, MEDLINE, EMBASE, Web of Science, Cochrane Library and ClinicalTrials.gov; hand searching for reference lists; contacted with authors if necessary. STUDY SELECTION All eligible trials were randomised clinical trials comparing PPIs with placebo in asthma patients accompanying with GERD. RESULTS Fourteen randomised clinical trials (2182 participants) were included. Overall, PPIs versus placebo did not affect mPEF in patients with asthma having GERD (weighted mean difference 8.68 L/min, 95% CI -2.02 to 19.37, p=0.11). Trial sequential analysis (TSA) further confirmed this finding (TSA adjusted 95% CI -1.03 to 22.25). Subgroups analyses based on the percentage of patients with symptomatic GERD≥95%, treatment duration >12 weeks also found no statistically significant benefit on mPEF. Similarly, analyses of secondary outcomes (evening PEF, forced expiratory volume in 1 s, asthma symptoms score, asthma quality of life score and episodes of asthma exacerbation) did not show significant difference between PPIs and placebo. CONCLUSION In this meta-analysis, PPIs therapy did not show a statistically significant improvement on mPEF in asthma patients having GERD, neither in subgroup with symptomatic GERD nor in subgroup with treatment duration >12 weeks. This analysis does not support a recommendation for PPIs therapy as empirical treatment in asthma patients with GERD. PROSPERO REGISTRATION NUMBER CRD42020177330.
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Affiliation(s)
- Zhoude Zheng
- Department of Pulmonary and Critical Care Medicine, Peking Union Medical College Hospital, Beijing, China
| | - Yunyun Luo
- Department of Endocrinology, Peking Union Medical College Hospital, Beijing, China
| | - Jia Li
- Department of Pulmonary and Critical Care Medicine, Peking Union Medical College Hospital, Beijing, China
| | - Jinming Gao
- Department of Pulmonary and Critical Care Medicine, Peking Union Medical College Hospital, Beijing, China
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15
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Launois C, Mulette P, Ancel J, Dury S, Hagenburg J, Lebargy F, Dormoy V, Deslee G, Perotin JM. [Treatment of GERD in asthma]. Rev Mal Respir 2021; 38:733-742. [PMID: 34016495 DOI: 10.1016/j.rmr.2021.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 03/25/2021] [Indexed: 11/28/2022]
Abstract
Gastro-oesophageal reflux disease (GORD) is one of the most frequent conditions associated with asthma. GORD has an impact on asthma control and quality of life of asthmatic patients. Its treatment relies on lifestyle modifications, anti-acidic treatment with proton pump inhibitors (PPI) and/or surgical management by fundoplication in some situations. The impact of lifestyle modifications has not been analysed on asthma outcomes alone. Several randomised controlled trials assessed the efficacy of PPI on asthma control, peak expiratory flow and/or quality of life. The impact of fundoplication in asthma has mainly been analysed in retrospective or prospective observational studies. This review highlights the limited impact of GORD treatment on asthma control. Current guidelines are to restrict GORD treatment in asthma to asthmatic patients with actual symptomatic GORD. Given the lack of controlled studies, the place of surgical management of GORD in asthma is currently not defined.
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Affiliation(s)
- C Launois
- Service des maladies respiratoires, CHU de Reims, 45, rue Cognacq-Jay, 51092 Reims cedex, France
| | - P Mulette
- Service des maladies respiratoires, CHU de Reims, 45, rue Cognacq-Jay, 51092 Reims cedex, France
| | - J Ancel
- Service des maladies respiratoires, CHU de Reims, 45, rue Cognacq-Jay, 51092 Reims cedex, France
| | - S Dury
- Service des maladies respiratoires, CHU de Reims, 45, rue Cognacq-Jay, 51092 Reims cedex, France; EA 4683, université de Reims Champagne-Ardenne, 51092 Reims, France
| | - J Hagenburg
- Service des maladies respiratoires, CHU de Reims, 45, rue Cognacq-Jay, 51092 Reims cedex, France
| | - F Lebargy
- Service des maladies respiratoires, CHU de Reims, 45, rue Cognacq-Jay, 51092 Reims cedex, France; EA 4683, université de Reims Champagne-Ardenne, 51092 Reims, France
| | - V Dormoy
- Inserm UMR-S 1250, P3Cell, université de Reims Champagne-Ardenne, 51092 Reims, France
| | - G Deslee
- Service des maladies respiratoires, CHU de Reims, 45, rue Cognacq-Jay, 51092 Reims cedex, France; Inserm UMR-S 1250, P3Cell, université de Reims Champagne-Ardenne, 51092 Reims, France
| | - J-M Perotin
- Service des maladies respiratoires, CHU de Reims, 45, rue Cognacq-Jay, 51092 Reims cedex, France; Inserm UMR-S 1250, P3Cell, université de Reims Champagne-Ardenne, 51092 Reims, France.
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16
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Kopsaftis Z, Yap HS, Tin KS, Hnin K, Carson-Chahhoud KV. Pharmacological and surgical interventions for the treatment of gastro-oesophageal reflux in adults and children with asthma. Cochrane Database Syst Rev 2021; 5:CD001496. [PMID: 33998673 PMCID: PMC8127576 DOI: 10.1002/14651858.cd001496.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Asthma and gastro-oesophageal reflux disease (GORD) are common medical conditions that frequently co-exist. GORD has been postulated as a trigger for asthma; however, evidence remains conflicting. Proposed mechanisms by which GORD causes asthma include direct airway irritation from micro-aspiration and vagally mediated oesophagobronchial reflux. Furthermore, asthma might precipitate GORD. Thus a temporal association between the two does not establish that GORD triggers asthma. OBJECTIVES To evaluate the effectiveness of GORD treatment in adults and children with asthma, in terms of its benefits for asthma. SEARCH METHODS The Cochrane Airways Group Specialised Register, CENTRAL, MEDLINE, Embase, reference lists of articles, and online clinical trial databases were searched. The most recent search was conducted on 23 June 2020. SELECTION CRITERIA We included randomised controlled trials comparing treatment of GORD in adults and children with a diagnosis of both asthma and GORD versus no treatment or placebo. DATA COLLECTION AND ANALYSIS A combination of two independent review authors extracted study data and assessed trial quality. The primary outcome of interest for this review was acute asthma exacerbation as reported by trialists. MAIN RESULTS The systematic search yielded a total of 3354 citations; 23 studies (n = 2872 participants) were suitable for inclusion. Included studies reported data from participants in 25 different countries across Europe, North and South America, Asia, Australia, and the Middle East. Participants included in this review had moderate to severe asthma and a diagnosis of GORD and were predominantly adults presenting to a clinic for treatment. Only two studies assessed effects of intervention on children, and two assessed the impact of surgical intervention. The remainder were concerned with medical intervention using a variety of dosing protocols. There was an uncertain reduction in the number of participants experiencing one or more moderate/severe asthma exacerbations with medical treatment for GORD (odds ratio 0.53, 95% confidence interval (CI) 0.17 to 1.63; 1168 participants, 2 studies; low-certainty evidence). None of the included studies reported data related to the other primary outcomes for this review: hospital admissions, emergency department visits, and unscheduled doctor visits. Medical treatment for GORD probably improved forced expiratory volume in one second (FEV₁) by a small amount (mean difference (MD) 0.10 L, 95% CI 0.05 to 0.15; 1333 participants, 7 studies; moderate-certainty evidence) as well as use of rescue medications (MD -0.71 puffs per day, 95% CI -1.20 to -0.22; 239 participants, 2 studies; moderate-certainty evidence). However, the benefit of GORD treatment for morning peak expiratory flow rate was uncertain (MD 6.02 L/min, 95% CI 0.56 to 11.47; 1262 participants, 5 studies). It is important to note that these mean improvements did not reach clinical importance. The benefit of GORD treatment for outcomes synthesised narratively including benefits of treatment for asthma symptoms, quality of life, and treatment preference was likewise uncertain. Data related to adverse events with intervention were generally underreported by the included studies, and those that were available indicated similar rates regardless of allocation to treatment or placebo. AUTHORS' CONCLUSIONS Effects of GORD treatment on the primary outcomes of number of people experiencing one or more exacerbations and hospital utilisation remain uncertain. Medical treatment for GORD in people with asthma may provide small benefit for a number of secondary outcomes related to asthma management. This review determined with moderate certainty that with treatment, lung function measures improved slightly, and use of rescue medications for asthma control was reduced. Further, evidence is insufficient to assess results in children, or to compare surgery versus medical therapy.
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Affiliation(s)
- Zoe Kopsaftis
- Respiratory Medicine Unit, The Queen Elizabeth Hospital, Central Adelaide Local Health Network, Adelaide, Australia
- School of Medicine, The University of Adelaide, Adelaide, Australia
- School of Health Sciences, University of South Australia, Adelaide, Australia
| | - Hooi Shan Yap
- Department of Respiratory and Sleep Medicine, Flinders Medical Centre, Adelaide, Australia
| | - Kyi Saw Tin
- Alice Springs Hospital, Alice Springs, Australia
| | - Khin Hnin
- Flinders University, Adelaide, Australia
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17
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Yagoubi A, Laid Y, Smati L, Nafissa Benhalla K, Benhassine F. Does omeprazole improve asthma-control in poorly-controlled asthmatic children with gastro-esophageal reflux. J Asthma 2021; 59:1169-1176. [PMID: 33866946 DOI: 10.1080/02770903.2021.1917606] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES The role of gastro-esophageal reflux disease (GERD) in poorly controlled asthma is often mentioned, but published studies have presented discordant results. Our main objective was to assess the effectiveness of GERD treatment in controlling asthma in children. METHODS We conducted a prospective study including poorly controlled asthmatic children aged 4 to 16 years. We checked the presence of acid reflux using pH monitoring. Patients with GERD were randomized into two groups; one received omeprazole for 6 months and the control group was not treated. The outcome was the score of the children asthma control test at the end of 6 months. The acid suppression was checked at the end of treatment with pH monitoring. After treatment, children with persistent acid reflux received high PPI doses and therefore were reevaluated 6 months later. RESULTS We included 102 children with poorly controlled asthma among which 59 (57.8%) had acid reflux. Gastroesophageal reflux (GER) was significantly more common in boys (p = 0.04). Treatment with omeprazole in sufficient doses improved the control of asthma in 5 children out of 6 (84.8 vs 11.5; p<.0001). Three factors appeared to be statistically associated with asthma control improvement after PPI therapy: male sex (p=.04), normal birth weight (p=.05) and a positive Prick-test (p=.05). These factors were not confirmed or were not sufficiently precise in multivariate analysis. The likelihood of a causal relationship between acid reflux and asthma, difficult to highlight with pH monitoring, was poor. CONCLUSIONS This study confirmed the high prevalence of GER in poorly controlled asthmatic children and showed the possible benefit of an efficient GER treatment in improving asthma control.
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Affiliation(s)
- Abdelghani Yagoubi
- Centre Algerois de Pediatrie, Pediatric gastroenterology, Algiers, Algeria
| | - Youcef Laid
- Institut National de Santé Publique, Unité santé et environnement, Algiers, Algeria
| | - Leila Smati
- Department of Pediatrics, Etablissement Public Hospitalier Bologhine Ibn Ziri, Hammamet, Algiers, Algeria
| | | | - Fadila Benhassine
- Department of Pediatrics, Etablissement Public Hospitalier Bologhine Ibn Ziri, Hammamet, Algiers, Algeria
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18
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Hozawa S, Maeda S, Kikuchi A, Koinuma M. Exploratory research on asthma exacerbation risk factors using the Japanese claims database and machine learning: A retrospective cohort study. J Asthma 2021; 59:1328-1337. [PMID: 33926352 DOI: 10.1080/02770903.2021.1923740] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Analytical studies of risk factor assessment using machine learning have recently been reported. We performed an exploratory detection study of asthma exacerbation-related factors using health insurance claims data and machine learning to explore risk factors that have high generalizability and can be easily obtained in daily practice. METHODS A dataset of asthma patients during May 2014-April 2019 from Japanese health insurance claims database, MediScope® (DB) was used. Patient characteristics and disease information were extracted, and association with occurrence of asthma exacerbation was evaluated to comprehensively search for exacerbation risk factors. Asthma exacerbations were defined as the co-occurrence of emergency medical procedures, such as emergency transport and intravenous steroid injections, with asthma claims, which were recorded in the database. RESULTS In total, 5,844 (13.7%) subjects had exacerbations in 42,685 eligible cases from the DB. Information on approximately 3,300 diseases was subjected to a machine learning, and 25 variables were extracted as variable importance and targeted for risk assessment. As a result, sex, days without exacerbation from cohort entry date at look-back period, Charlson Comorbidity Index, allergic rhinitis, chronic sinusitis, acute airway disease (upper airway), acute airway disease (lower airways), Chronic obstructive pulmonary disease/chronic bronchitis, gastroesophageal reflux disease, and hypertension were significantly associated with exacerbation. Dyslipidemia and periodontitis were detected as associated factors of reduced exacerbation risk. CONCLUSIONS A comprehensive analysis of claims data using machine learning showed asthma exacerbation risk factors mostly consistent with those in previous studies. Further examination in other fields is warranted.
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Affiliation(s)
| | | | | | - Masayoshi Koinuma
- Faculty of Pharmaceutical Sciences, Teikyo Heisei University, Tokyo, Japan
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19
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Paoletti G, Melone G, Ferri S, Puggioni F, Baiardini I, Racca F, Canonica GW, Heffler E, Malipiero G. Gastroesophageal reflux and asthma: when, how, and why. Curr Opin Allergy Clin Immunol 2021; 21:52-58. [PMID: 33369569 DOI: 10.1097/aci.0000000000000705] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Gastro-esophageal reflux is a possible cause of uncontrolled symptoms of asthma and should be actively investigated and treated before severe asthma is diagnosed and biological therapy started. RECENT FINDINGS Recent investigations on esophageal function and tissue biomarkers in patients with asthma and associated GERD have established a relevant role for esophageal motility and neuronal sensory abnormalities in linking the two diseases. Characterization of the underpinning inflammatory substrate has showed mixed results as both neutrophilic and eosinophilic type 2 inflammatory changes have been described. SUMMARY New findings regarding inflammatory mechanisms in GERD-associated asthma as well as new diagnostic tools to investigate functional esophageal abnormalities and characterize asthma endotype have identified potential treatable traits that may improve the clinical management and outcome of asthmatic patients with GERD.
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Affiliation(s)
- Giovanni Paoletti
- Personalized Medicine, Asthma and Allergy, Humanitas Clinical and Research Center, IRCCS, Rozzano
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Giulio Melone
- Personalized Medicine, Asthma and Allergy, Humanitas Clinical and Research Center, IRCCS, Rozzano
| | - Sebastian Ferri
- Personalized Medicine, Asthma and Allergy, Humanitas Clinical and Research Center, IRCCS, Rozzano
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Francesca Puggioni
- Personalized Medicine, Asthma and Allergy, Humanitas Clinical and Research Center, IRCCS, Rozzano
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Ilaria Baiardini
- Personalized Medicine, Asthma and Allergy, Humanitas Clinical and Research Center, IRCCS, Rozzano
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Francesca Racca
- Personalized Medicine, Asthma and Allergy, Humanitas Clinical and Research Center, IRCCS, Rozzano
| | - Giorgio W Canonica
- Personalized Medicine, Asthma and Allergy, Humanitas Clinical and Research Center, IRCCS, Rozzano
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Enrico Heffler
- Personalized Medicine, Asthma and Allergy, Humanitas Clinical and Research Center, IRCCS, Rozzano
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Giacomo Malipiero
- Personalized Medicine, Asthma and Allergy, Humanitas Clinical and Research Center, IRCCS, Rozzano
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20
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Abstract
Microaspiration, or silent aspiration, is commonly suspected in patients with refractory respiratory symptoms, including unexplained chronic cough, asthma, chronic obstructive pulmonary disease, bronchiolitis, bronchiectasis, and idiopathic pulmonary fibrosis. This suspicion is driven by the high prevalence of gastroesophageal reflux in these otherwise disparate disorders. Frequently, patients receive aggressive treatment for gastroesophageal reflux disease as a means of treating their underlying respiratory conditions, even in the absence of overt symptoms of reflux. However, clinical trials have not demonstrated a clear impact on outcomes with this strategy, and in some instances there may be potential for harm. Mechanistic studies have increasingly used gastric biomarkers obtained directly from the airways to confirm the association between reflux and respiratory disease, but results are limited by methodologic flaws and correlation. The best evidence of aspiration directly causing respiratory disorders is the histopathologic detection of foreign bodies. For most of the other chronic respiratory disorders, microaspiration may be uncommon or a secondary aggravating factor, as in patients with acute exacerbations of chronic obstructive pulmonary disease or idiopathic pulmonary fibrosis. In some cases, microaspiration is probably not a significant factor at all, such as in unexplained chronic cough. It is important to distinguish between conditions in which aspiration is primarily or directly causal and conditions in which aspiration may be indirectly aggravating, to help identify whether interventions targeting reflux and aspiration precautions should be recommended to patients. Our clinical review examines some of the evidence supporting reflux-aspiration as a mechanism for several chronic respiratory disorders and offers some management considerations when reflux-aspiration is suspected.
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21
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McDonnell MJ, Hunt EB, Ward C, Pearson JP, O'Toole D, Laffey JG, Murphy DM, Rutherford RM. Current therapies for gastro-oesophageal reflux in the setting of chronic lung disease: state of the art review. ERJ Open Res 2020; 6:00190-2019. [PMID: 33693049 PMCID: PMC7927787 DOI: 10.1183/23120541.00190-2019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 08/12/2020] [Indexed: 12/13/2022] Open
Abstract
The inter-relationship between chronic respiratory disease and reflux disease in the airway reflux paradigm is extremely complex and remains poorly characterised. Reflux disease is reported to cause or contribute to the severity of a number of respiratory tract diseases including laryngeal disorders, sinusitis, chronic cough, asthma, COPD, idiopathic pulmonary fibrosis, cystic fibrosis, bronchiectasis and bronchiolitis obliterans post lung transplant. It is now appreciated that reflux disease is not simply caused by liquid acid reflux but rather by a variety of chemical refluxates originating from the stomach and duodenum due to a number of different mechanisms. Reflux disease can be challenging to diagnose, particularly proving its role in the causation of direct respiratory epithelial damage. Significant advances in oesophageal assessment and gastric biomarkers have emerged in recent years as our understanding increases. There are a number of treatments available for reflux disease, both medical and surgical, but there is a paucity of large randomised trials to evaluate their efficacy in the setting of chronic respiratory disease. Everyday clinical practice, however, informs us that treatment failure in reflux disease is common. This clinical review summarises associations between reflux disease in the setting of chronic respiratory diseases and examines available evidence regarding potential therapeutic strategies. Gastro-oesophageal reflux disease is prevalent among patients with chronic respiratory disease. A number of medical and surgical treatment options are available for GORD. This review examines available evidence in the setting of chronic lung disease.https://bit.ly/34TcMJS
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Affiliation(s)
- Melissa J McDonnell
- Dept of Respiratory Medicine, Galway University Hospitals, Galway, Ireland.,Lung Biology Group, National University of Ireland, Galway, Ireland.,Institute of Cell and Molecular Biosciences, Newcastle University, Newcastle, UK
| | - Eoin B Hunt
- Dept of Respiratory Medicine, Cork University Hospital, Cork, Ireland.,The Clinical Research Facility, University College Cork, Cork, Ireland
| | - Chris Ward
- Institute of Cell and Molecular Biosciences, Newcastle University, Newcastle, UK
| | - Jeffrey P Pearson
- Institute of Cell and Molecular Biosciences, Newcastle University, Newcastle, UK
| | - Daniel O'Toole
- Lung Biology Group, National University of Ireland, Galway, Ireland
| | - John G Laffey
- Lung Biology Group, National University of Ireland, Galway, Ireland
| | - Desmond M Murphy
- Dept of Respiratory Medicine, Cork University Hospital, Cork, Ireland.,The Clinical Research Facility, University College Cork, Cork, Ireland
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22
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Abstract
Bronchial asthma is characterized by chronic airway inflammation, which manifests clinically as variable airway narrowing (wheezes and dyspnea) and cough. Long-standing asthma may induce airway remodeling and become intractable. The prevalence of asthma has increased; however, the number of patients who die from it has decreased (1.3 per 100,000 patients in 2018). The goal of asthma treatment is to control symptoms and prevent future risks. A good partnership between physicians and patients is indispensable for effective treatment. Long-term management with therapeutic agents and the elimination of the triggers and risk factors of asthma are fundamental to its treatment. Asthma is managed by four steps of pharmacotherapy, ranging from mild to intensive treatments, depending on the severity of disease; each step includes an appropriate daily dose of an inhaled corticosteroid, which may vary from low to high. Long-acting β2-agonists, leukotriene receptor antagonists, sustained-release theophylline, and long-acting muscarinic antagonists are recommended as add-on drugs, while anti-immunoglobulin E antibodies and other biologics, and oral steroids are reserved for very severe and persistent asthma related to allergic reactions. Bronchial thermoplasty has recently been developed for severe, persistent asthma, but its long-term efficacy is not known. Inhaled β2-agonists, aminophylline, corticosteroids, adrenaline, oxygen therapy, and other approaches are used as needed during acute exacerbations, by selecting treatment steps for asthma based on the severity of the exacerbations. Allergic rhinitis, eosinophilic chronic rhinosinusitis, eosinophilic otitis, chronic obstructive pulmonary disease, aspirin-exacerbated respiratory disease, and pregnancy are also important conditions to be considered in asthma therapy.
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23
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Cho JH, Shin CM, Yoon H, Park YS, Kim N, Lee DH. Efficacy of a high-dose proton pump inhibitor in patients with gastroesophageal reflux disease: a single center, randomized, open-label trial. BMC Gastroenterol 2020; 20:275. [PMID: 32811427 PMCID: PMC7433117 DOI: 10.1186/s12876-020-01410-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 08/07/2020] [Indexed: 11/22/2022] Open
Abstract
Background The extraesophageal manifestations of gastroesophageal reflux disease (GERD) are more difficult to manage than the typical symptoms. The efficacy of high-dose and standard-dose proton pump inhibitors against these atypical symptoms is not yet established. Methods In this single center, randomized, open-label study, patients with GERD received rabeprazole for 8 weeks, either 20 mg once daily (standard-dose group) or 20 mg twice daily (high-dose group). Patients were assessed before treatment and at weeks 4 and 8 with a 5-graded scale questionnaire consisting of 2 typical symptoms (heartburn and acid regurgitation) and 8 atypical symptoms (chest pain, cough, globus, wheezing, laryngopharyngitis, hoarseness, belching, and dysphagia). Sufficient improvement of reflux symptoms was defined as ≥50% reduction from the initial questionnaire score. Results Final analyses included 35 patients in the standard-dose group and 38 patients in the high-dose group. The rate of sufficient improvement for typical symptoms was significantly higher in the high-dose group than in the standard-dose group (100.0% vs. 84.0%, P = 0.040). For atypical symptoms, the rate of sufficient improvement tended to be higher in the high-dose group than in the standard-dose group (82.4% vs. 63.0%, P = 0.087). Scores of typical and some atypical symptoms (cough and globus) improved after treatment, with significant inter-group differences in time-course changes. Conclusions High-dose rabeprazole is more effective for relieving typical GERD symptoms and some atypical symptoms such as cough and globus than a standard-dose regimen. Trial registration This research was enrolled in a registry of clinical trials run by United States National Library of Medicine at the National Institutes of Health (ClinicalTrials.gov Protocol Registration and Results system ID: NCT04001400). This study was registered on June 26, 2019 - Retrospectively registered.
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Affiliation(s)
- Jae Ho Cho
- Department of Internal Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam, Gyeonggi-do, 13620, South Korea
| | - Cheol Min Shin
- Department of Internal Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam, Gyeonggi-do, 13620, South Korea
| | - Hyuk Yoon
- Department of Internal Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam, Gyeonggi-do, 13620, South Korea
| | - Young Soo Park
- Department of Internal Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam, Gyeonggi-do, 13620, South Korea
| | - Nayoung Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam, Gyeonggi-do, 13620, South Korea
| | - Dong Ho Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam, Gyeonggi-do, 13620, South Korea.
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24
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Chan WW, Ahuja N, Fisichella PM, Gavini S, Rangan V, Vela MF. Extraesophageal syndrome of gastroesophageal reflux: relationships with lung disease and transplantation outcome. Ann N Y Acad Sci 2020; 1482:95-105. [PMID: 32808313 DOI: 10.1111/nyas.14460] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 07/05/2020] [Accepted: 07/15/2020] [Indexed: 12/14/2022]
Abstract
Gastroesophageal reflux disease (GERD) is prevalent and may be associated with both esophageal and extraesophageal syndromes, which include various pulmonary conditions. GERD may lead to pulmonary complications through the "reflux" (aspiration) or "reflex" (refluxate-triggered, vagally mediated airway spasm) mechanisms. While GERD may cause or worsen pulmonary disorders, changes in respiratory mechanics due to lung disease may also increase reflux. Typical esophageal symptoms are frequently absent and objective assessment with reflux monitoring is often needed for diagnosis. Impedance monitoring should be considered in addition to traditional pH study due to the involvement of both acidic and weakly acidic/nonacidic reflux. Antireflux therapy may improve outcomes of some pulmonary complications of GERD, although careful selection of a candidate is paramount to successful outcomes. Further research is needed to identify the optimal testing strategy and patient phenotypes that would benefit from antireflux therapy to improve pulmonary outcomes.
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Affiliation(s)
- Walter W Chan
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Nitin Ahuja
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - P Marco Fisichella
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Sravanya Gavini
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Vikram Rangan
- Division of Gastroenterology, Hepatology, and Nutrition, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Marcelo F Vela
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona
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25
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Griffiths TL, Nassar M, Soubani AO. Pulmonary manifestations of gastroesophageal reflux disease. Expert Rev Respir Med 2020; 14:767-775. [PMID: 32308062 DOI: 10.1080/17476348.2020.1758068] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 04/16/2020] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Gastroesophageal reflux disease (GERD) is a widespread condition with a significant impact on the quality of life and healthcare resources. In addition to its gastrointestinal problems, GERD has been linked to a variety of respiratory diseases either as a direct cause, or as a risk factor to the inability to control or worsening of the disease. AREAS COVERED We performed a literature search in the PubMed database for articles addressing GERD and pulmonary diseases. This review will discuss several different pulmonary diseases affected by GERD ranging from upper airway including chronic cough, vocal cord dysfunction, lower airway diseases including COPD, asthma, and bronchiolitis obliterans syndrome to parenchymal diseases such as interstitial lung diseases. The review will discuss several different pulmonary manifestations of GERD and their contribution to patient mortality and morbidity. It will also review the mechanisms leading to these diseases, diagnostic workup, and the role of the available treatment options. EXPERT OPINION GERD is often overlooked as a cause of respiratory symptoms and illnesses. The literature is sparse on the relation between GERD and respiratory diseases such as interstitial lung diseases and bronchiolitis obliterans including its role in pathogenesis, mechanisms of lung injury, and whether treatment of GERD is effective in managing such illnesses.
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Affiliation(s)
- Tricia L Griffiths
- Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State University School of Medicine , Detroit, MI, USA
| | - Mo'ath Nassar
- Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State University School of Medicine , Detroit, MI, USA
| | - Ayman O Soubani
- Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State University School of Medicine , Detroit, MI, USA
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26
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Abstract
Background: Severe asthma can be a challenging disease to manage by the provider and by the patient, supported by evidence of increased health-care utilization by this population. Patients with severe asthma should be screened for comorbidities because these often contribute to poorly controlled asthma. The impact of comorbidities, however, are not completely understood. Objective: To review common comorbidities and their impact on severe asthma. Methods: A review of relevant clinical research studies that examined comorbidities in severe or difficult-to-treat asthma. Results: A number of comorbid diseases, including rhinitis, rhinosinusitis, gastroesophageal reflux, and obstructive sleep apnea, are associated with severe or difficult-to-treat asthma. If present and untreated, these conditions may adversely affect asthma control, quality of life, and/or lung function, despite adequate treatment with step-up asthma controller therapy. Conclusion: Treatable comorbidities are associated with severe and difficult-to-control asthma. Failure to recognize these comorbidities may divert appropriate care and increase disease burden. Assessment and management of these risk factors may contribute to improved asthma outcome; however, more investigation is needed to understand the relationship of comorbidities and asthma due to inconsistency in the findings.
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Affiliation(s)
- Gayatri B Patel
- Division of Allergy and Immunology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Anju T Peters
- Division of Allergy and Immunology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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27
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Bardin PG, Rangaswamy J, Yo SW. Managing comorbid conditions in severe asthma. Med J Aust 2019; 209:S11-S17. [PMID: 30453867 DOI: 10.5694/mja18.00196] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 11/20/2018] [Indexed: 12/26/2022]
Abstract
Asthma care has increasingly focused on personalised management for severe asthma, and recognition of the role and importance of comorbid conditions has increased. Severe asthma can be crippling; associated comorbid conditions often play a key role in the significant disease morbidity and frequently contribute to a severe and difficult-to-treat asthma phenotype. Comorbid conditions can be broadly grouped as being either airway-related or airway-unrelated. Airway-related comorbid conditions with the greatest impact are allergic rhinitis, chronic rhinosinusitis, vocal cord dysfunction, lung fungal sensitisation and underlying structural lung disease. The most important airway-unrelated comorbid conditions are obesity, obstructive sleep apnoea, gastro-oesophageal reflux disease and anxiety and depression. A diagnostic and management algorithm for comorbid conditions in severe asthma is outlined. It concentrates initially on the group with common comorbid conditions that can be managed in primary care. If asthma remains troublesome, emphasis can shift to identifying uncommon and more complex factors. The algorithm allows for personalised diagnostic and management pathways to be implemented. Personalised diagnosis and management of comorbid conditions are essential to achieving effective and improved outcomes for patients with severe asthma.
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Affiliation(s)
- Philip G Bardin
- Monash Lung and Sleep, Monash Hospital and University, Melbourne, VIC
| | | | - Shaun W Yo
- Monash Lung and Sleep, Monash Hospital and University, Melbourne, VIC
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28
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Ioachimescu OC, Desai NS. Nonallergic Triggers and Comorbidities in Asthma Exacerbations and Disease Severity. Clin Chest Med 2018; 40:71-85. [PMID: 30691718 DOI: 10.1016/j.ccm.2018.10.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Asthma triggers are exogenous or endogenous factors that could worsen asthma acutely to cause an exacerbation, or perpetuate chronic symptoms and airflow limitation. Because it is well known that recent asthma exacerbations and poor symptom control are strong predictors of future disease activity, it is not surprising that the number of (allergic or nonallergic) asthma triggers in the environment correlates with the disease-related quality of life. There is a need to identify and avoid specific triggers as the centerpiece of disease management, especially in those with heightened sensitivity to certain factors.
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Affiliation(s)
- Octavian C Ioachimescu
- Pulmonary, Critical Care and Sleep Medicine, Emory University, Atlanta VA Medical Center, Atlanta, GA, USA
| | - Nikita S Desai
- Pulmonary and Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA.
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29
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DeBoer EM, Kinder S, Duggar A, Prager JD, Soden J, Deterding RR, Ruiz AG, Jensen EL, Weinman J, Wine T, Fortunato JE, Friedlander JA. Evaluating the yield of gastrointestinal testing in pediatric patients in aerodigestive clinic. Pediatr Pulmonol 2018; 53:1517-1524. [PMID: 30288952 DOI: 10.1002/ppul.24170] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 07/30/2018] [Accepted: 09/05/2018] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To improve understanding of the interrelatedness of airway and esophageal diagnoses by evaluating the yield of procedural and radiographic testing of the gastrointestinal tract in children with airway conditions by their referring diagnoses in a pediatric aerodigestive clinic. METHODS A retrospective chart review of all 325 patients seen in the aerodigestive program from 2010 to 2013 was performed in a single academic medical center. Demographics and results from esophagogastroduodenoscopies with biopsies (EGD), upper gastrointestinal fluoroscopy studies (UGI), and pH multichannel intraluminal impedance probe (pH-MII) performed within 30 days of the clinic visit were evaluated according to presenting diagnoses. RESULTS Mean patient age was 3.15 years (range 0.15-24 years) and 41.2% were born premature. 189/325 (58.1%) were on acid suppression. A total of 295 EGD, 193 pH-MII, and 54 UGI were performed. The most common diagnosis with an abnormal pH-MII was asthma. The most common diagnoses with an abnormal EGD were feeding difficulty and tracheal esophageal fistula/ esophageal atresia (TEF/EA). EGDs were normal in 188/295 (63.7%), while 39/295 (13.2%) demonstrated esophagitis, and 22/295 (7.5%) had >15 esophageal eosinophils per high power field. The majority of pH-MII (144/193 [74.6%]) and UGI (47/54 [87%]) were normal. CONCLUSIONS Children with feeding difficulty, TEF/EA, and asthma were the mostly likely to have a histologic abnormality on EGD or an abnormal pH-MII. The majority of children were previously prescribed acid suppression medication and had a referring diagnosis of gastroesophageal reflux disease but were subsequently found to have normal evaluation. Prospective studies are needed to optimize care of this population.
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Affiliation(s)
- Emily M DeBoer
- Breathing Institute, Children's Hospital Colorado, Aurora, Colorado.,University of Colorado School of Medicine, Department of Pediatrics, Aurora, Colorado.,Aerodigestive Program, Children's Hospital Colorado, Aurora, Colorado
| | - Sarah Kinder
- University of Colorado School of Medicine, Department of Pediatrics, Aurora, Colorado.,Digestive Health Institute, Children's Hospital Colorado, Aurora, Colorado
| | - Alison Duggar
- University of Colorado School of Medicine, Department of Pediatrics, Aurora, Colorado
| | - Jeremy D Prager
- Aerodigestive Program, Children's Hospital Colorado, Aurora, Colorado.,University of Colorado School of Medicine, Department of Otolaryngology, Aurora, Colorado
| | - Jason Soden
- University of Colorado School of Medicine, Department of Pediatrics, Aurora, Colorado.,Aerodigestive Program, Children's Hospital Colorado, Aurora, Colorado.,Digestive Health Institute, Children's Hospital Colorado, Aurora, Colorado
| | - Robin R Deterding
- Breathing Institute, Children's Hospital Colorado, Aurora, Colorado.,University of Colorado School of Medicine, Department of Pediatrics, Aurora, Colorado.,Aerodigestive Program, Children's Hospital Colorado, Aurora, Colorado
| | - Amanda G Ruiz
- University of Colorado School of Medicine, Department of Otolaryngology, Aurora, Colorado
| | - Emily L Jensen
- University of Colorado School of Medicine, Department of Otolaryngology, Aurora, Colorado
| | - Jason Weinman
- Children's Hospital Colorado, Department of Radiology, Aurora, Colorado
| | - Todd Wine
- Aerodigestive Program, Children's Hospital Colorado, Aurora, Colorado.,University of Colorado School of Medicine, Department of Otolaryngology, Aurora, Colorado
| | - John E Fortunato
- Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Joel A Friedlander
- University of Colorado School of Medicine, Department of Pediatrics, Aurora, Colorado.,Aerodigestive Program, Children's Hospital Colorado, Aurora, Colorado.,Digestive Health Institute, Children's Hospital Colorado, Aurora, Colorado
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30
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Durrani SR, Mukkada VA, Guilbert TW. Eosinophilic Esophagitis: an Important Comorbid Condition of Asthma? Clin Rev Allergy Immunol 2018; 55:56-64. [PMID: 29455359 DOI: 10.1007/s12016-018-8670-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Eosinophilic esophagitis and asthma are frequently found as comorbid conditions in children and adults along with other manifestations of atopic diathesis. These two conditions have similar T helper 2 responses-driven pathophysiology and share common management strategies such as using systemic corticosteroids and targeted anti-cytokine biologic therapies. Review of the literature finds that asthma is often a comorbid condition in eosinophilic esophagitis in both children and adults; however, the EoE-asthma relationship remains poorly characterized mechanistically and clinically. EoE and asthma commonly share several comorbid conditions such as allergic rhinitis and gastroesophageal reflux disease; therefore, addressing these comorbid conditions has the potential to improve and/or maintain control in both diseases. Similar to asthma, patients with EoE frequently demonstrate elevations in serum markers of atopy, including serum IgE levels, peripheral eosinophil counts, and T helper 2-related cytokines. Gastroesophageal reflux disease is thought to affect asthma through microaspirations, airway hyperresponsiveness, and increased vagal tone. The understanding of the relationship between gastroesophageal reflux and EoE is still evolving but seems to be bidirectional and interactive. In terms of treatment, similar classes of medications have been used in both EoE and asthma. In both children and adults, EoE remission can be achieved by food trigger avoidance and use of corticosteroids and biologic therapies. Asthma control is mostly achieved through inhaled corticosteroids, and long but biologic therapies are increasingly used in severe subsets of the disease. Significant clinical and mechanistic work needs to be accomplished to better understand the relationship between asthma, EoE, and their interaction with other allergic diseases. Understanding whether shared mechanisms exist can lead to the development of new diagnostic and therapeutic strategies. The following review examines the existing literature regarding prevalence, common comorbidities, and potential therapeutic approach and identifies gaps in knowledge and future directions.
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Affiliation(s)
- Sandy R Durrani
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA. .,Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA. .,Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
| | - Vincent A Mukkada
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Division of Gastroenterology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Theresa W Guilbert
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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31
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Tang M, Henderson RJ, Holbrook JT, Que LG, Mathews AM, Wise RA, Dixon AE, Peters SP, Rogers L, Smith LJ, Teague WG, Lang JE. Does Obesity Increase Respiratory Tract Infections in Patients with Asthma? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 7:954-961.e6. [PMID: 30312805 DOI: 10.1016/j.jaip.2018.09.033] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 09/06/2018] [Accepted: 09/26/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Because respiratory tract infections (RTIs) precede most exacerbations, a better understanding of the risk factors of RTIs and RTI-associated exacerbations in patients with asthma is a pressing public health need. Obesity in patients with asthma is associated with worse asthma control and higher asthma-associated health care utilization, but its effect on RTI risk is unknown. OBJECTIVE We aimed to study the association of body mass index (BMI) classification on the risk of self-reported RTIs and related asthma morbidity among adults and children with asthma. METHODS This post hoc analysis of 5 large asthma trials involving 747 children and 1287 adults compared BMI classification, defined as lean, overweight, and obese based on age-appropriate BMI and BMI-percentile conventions. The primary outcome was rate of visits with RTIs. Secondary asthma outcomes included upper respiratory infection (URI) severity, systemic steroid use, and health care contact. RESULTS Children had 1.4 times the rate of RTI compared with adults (95% confidence interval 1.27-1.56). In all participants, BMI classification did not affect the rate of visits with RTI. In children, BMI classification did not affect URI severity, all-cause asthma events, or RTI-associated asthma events. However, in adults, higher BMI classification was associated with an increase in moderate/severe URI (P = .02). Adults with higher BMI classification also had increased rates of all-cause and RTI-associated asthma exacerbations requiring systemic steroids and health care contact. CONCLUSIONS BMI classification was not associated with an increased risk of RTIs in children or adults. In adults only, obesity was associated with increased URI severity and all-cause and RTI-associated asthma morbidity.
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Affiliation(s)
- Monica Tang
- Department of Pediatrics, Duke University, Durham, NC.
| | | | - Janet T Holbrook
- Department of Epidemiology, Johns Hopkins University, Baltimore, Md
| | | | | | - Robert A Wise
- Department of Medicine, Johns Hopkins University, Baltimore, Md
| | - Anne E Dixon
- Department of Medicine, University of Vermont, Burlington, Vt
| | - Stephen P Peters
- Department of Medicine, Wake Forest University, Winston-Salem, NC
| | - Linda Rogers
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Lewis J Smith
- Department of Medicine, Northwestern University, Chicago, Ill
| | - W Gerald Teague
- Department of Pediatrics, University of Virginia, Charlottesville, Va
| | - Jason E Lang
- Department of Pediatrics, Duke University, Durham, NC
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32
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Batchelor R, Kumar R, Gilmartin-Thomas JFM, Hopper I, Kemp W, Liew D. Systematic review with meta-analysis: risk of adverse cardiovascular events with proton pump inhibitors independent of clopidogrel. Aliment Pharmacol Ther 2018; 48:780-796. [PMID: 30178881 DOI: 10.1111/apt.14955] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 06/24/2018] [Accepted: 07/31/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Clopidogrel's anti-platelet effects may be attenuated by a pharmacokinetic interaction with co-prescribed proton pump inhibitors, which inhibit oxidative pathways that convert clopidogrel into its active metabolites. Despite this, the impact of PPIs on cardiovascular risk in the absence of clopidogrel is not well defined. AIM To report on a systematic review and meta-analysis of the association between PPIs and cardiovascular risk, independent of clopidogrel. METHODS The databases of MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Scopus, Web of Science, and ClinicalTrials.gov were systematically searched in October 2017. The primary outcome was association between PPI monotherapy and any adverse cardiovascular event. The secondary outcome was association between proton pump inhibitor monotherapy and acute myocardial infarction. Studies were excluded if they reported or did not adjust for concomitant anti-platelet therapy or involved participants aged less than 18 years. RESULTS A total of 22 studies were included in the systematic review. Data from 16 studies were included in the meta-analysis (involving 447 408 participants). Of these, eight were randomised controlled trials, seven were observational studies and one was a retrospective analysis of a randomised controlled trial. An increased risk of any adverse cardiovascular event with PPI monotherapy was observed using pooled data from observational studies (risk ratio 1.25, 95% CI 1.11-1.42, I2 81%, P < 0.001), but not from randomised controlled trials (risk ratio 0.89, 95% CI 0.34-2.33, I2 0%, P = 0.85). CONCLUSION There is no clear evidence of an association between PPI monotherapy and increased cardiovascular risk.
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Affiliation(s)
- Riley Batchelor
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Radya Kumar
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Julia F M Gilmartin-Thomas
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Research Department of Practice and Policy, University College London School of Pharmacy, London, UK
| | - Ingrid Hopper
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - William Kemp
- Department of Gastroenterology, Alfred Health, Melbourne, Australia
| | - Danny Liew
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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33
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Lupu VV, Burlea M, Nistor N, Streanga V, Starcea MI, Paduraru G, Ghica DC, Mitrofan EC, Moscalu M, Ignat A. Correlation between esophageal pH-metry and esophagitis in gastroesophageal reflux disease in children. Medicine (Baltimore) 2018; 97:e12042. [PMID: 30212934 PMCID: PMC6156075 DOI: 10.1097/md.0000000000012042] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Gastroesophageal reflux (GER) is the intermittent or permanent passage of stomach content into the esophagus and gastroesophageal reflux disease (GERD) is the reflux which triggers a whole set of symptoms or complications. The study compares the 24-hours esophageal pH-metry, used for diagnosis of the GERD, with the esophagitis degree observed at the upper digestive endoscopy.72 children were included, aged over 4 years old, admitted in a pediatric gastroenterology regional center in Northeast Romania, diagnosed with GERD by 24 hours pH-metry (with a positive Boix-Ochoa score), which also underwent the upper digestive endoscopy.Out of the 72 children diagnosed with GERD, 47 (65.28%) had grade A esophagitis and 25 (34.72%) grade B esophagitis. In GERD associated with grade B esophagitis the Boix-Ochoa score is statistically significant higher, compared with the GERD associated with grade A esophagitis (F = 9.76, P = .0036, 95% CI).Upper digestive endoscopy performed in patients with gastroesophageal reflux disease shows the constant presence of esophagitis at all patients. There were only grade A and B esophagitis due to the fact that they are young patients with a relative short history of the disease. The correlation tests show a perfect parallel between the pH-metry scores and the endoscopic lesion. The correlation is so accurate that the pH-metry scores can be sufficient to prove GERD and the grade of esophagitis, the upper digestive endoscopy being reserved only for the cases that does not respond to the medical treatment or have other complications.
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Affiliation(s)
| | | | | | | | | | | | - Dragos Catalin Ghica
- Preventive Medicine Department, University of Medicine and Pharmacy “Grigore T. Popa”
| | | | - Mihaela Moscalu
- Medical Informatics and Biostatistics Department, University of Medicine and Pharmacy “Gr. T. Popa”, Iasi, Romania
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34
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Tay TR, Hew M. Comorbid "treatable traits" in difficult asthma: Current evidence and clinical evaluation. Allergy 2018; 73:1369-1382. [PMID: 29178130 DOI: 10.1111/all.13370] [Citation(s) in RCA: 111] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2017] [Indexed: 01/07/2023]
Abstract
The care of patients with difficult-to-control asthma ("difficult asthma") is challenging and costly. Despite high-intensity asthma treatment, these patients experience poor asthma control and face the greatest risk of asthma morbidity and mortality. Poor asthma control is often driven by severe asthma biology, which has appropriately been the focus of intense research and phenotype-driven therapies. However, it is increasingly apparent that extra-pulmonary comorbidities also contribute substantially to poor asthma control and a heightened disease burden. These comorbidities have been proposed as "treatable traits" in chronic airways disease, adding impetus to their evaluation and management in difficult asthma. In this review, eight major asthma-related comorbidities are discussed: rhinitis, chronic rhinosinusitis, gastroesophageal reflux, obstructive sleep apnoea, vocal cord dysfunction, obesity, dysfunctional breathing and anxiety/depression. We describe the prevalence, impact and treatment effects of these comorbidities in the difficult asthma population, emphasizing gaps in the current literature. We examine the associations between individual comorbidities and highlight the potential for comorbidity clusters to exert combined effects on asthma outcomes. We conclude by outlining a pragmatic clinical approach to assess comorbidities in difficult asthma.
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Affiliation(s)
- T. R. Tay
- Allergy, Asthma and Clinical Immunology; The Alfred Hospital; Melbourne Vic. Australia
- Department of Respiratory and Critical Care Medicine; Changi General Hospital; Singapore
| | - M. Hew
- Allergy, Asthma and Clinical Immunology; The Alfred Hospital; Melbourne Vic. Australia
- School of Public Health & Preventive Medicine; Monash University; Melbourne Vic. Australia
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35
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Lee AS, Ryu JH. Aspiration Pneumonia and Related Syndromes. Mayo Clin Proc 2018; 93:752-762. [PMID: 29730088 DOI: 10.1016/j.mayocp.2018.03.011] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 03/12/2018] [Accepted: 03/14/2018] [Indexed: 01/08/2023]
Abstract
Aspiration is a syndrome with variable respiratory manifestations that span acute, life-threatening illnesses, such as acute respiratory distress syndrome, to chronic, sometimes insidious, respiratory disorders such as aspiration bronchiolitis. Diagnostic testing is limited by the insensitivity of histologic testing, and although gastric biomarkers for aspiration are increasingly available, none have been clinically validated. The leading mechanism for microaspiration is thought to be gastroesophageal reflux disease, largely driven by the increased prevalence of gastroesophageal reflux across a variety of respiratory disorders, including chronic obstructive pulmonary disease, asthma, idiopathic pulmonary fibrosis, and chronic cough. Failure of therapies targeting gastric acidity in clinical trials, in addition to increasing concerns about both the overuse of and adverse events associated with proton pump inhibitors, raise questions about the precise mechanism and causal link between gastroesophageal reflux and respiratory disease. Our review summarizes key aspiration syndromes with a focus on reflux-mediated aspiration and highlights the need for additional mechanistic studies to find more effective therapies for aspiration syndromes.
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Affiliation(s)
- Augustine S Lee
- Division of Pulmonary, Allergy and Sleep Medicine, Mayo Clinic, Jacksonville, FL.
| | - Jay H Ryu
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
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36
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Broers C, Tack J, Pauwels A. Review article: gastro-oesophageal reflux disease in asthma and chronic obstructive pulmonary disease. Aliment Pharmacol Ther 2018; 47:176-191. [PMID: 29193245 DOI: 10.1111/apt.14416] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 05/29/2017] [Accepted: 10/20/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND When gastro-oesophageal reflux is causing symptoms or lesions in the oesophagus, this is referred to as gastro-oesophageal reflux disease (GERD). GERD can manifest itself through typical symptoms (heartburn, regurgitation) or may lead to extra-oesophageal symptoms. Extra-oesophageal manifestations of GERD gained increasing attention over the last decade, especially respiratory disorders, because of the prevalent co-occurrence with GERD. The role of GERD in the pathogenesis of respiratory disorders has become a topic of intense discussion. AIM To provide an overview of the current knowledge on the role of GERD in asthma and chronic obstructive pulmonary disease (COPD). METHODS PubMed was searched for relevant articles using the keywords: GERD, asthma, COPD, prevalence, treatment. Case reports were excluded, only English language articles were considered. RESULTS Estimates for the prevalence of GERD in asthma range from 30% to 90%, compared to an average of 24% in controls. In COPD patients, the prevalence of GERD ranges from 19% to 78% compared to an average of 18% in controls. These data indicate an increased prevalence of GERD in patients with asthma and COPD, although causality is not established and GERD treatment yielded inconsistent effects. Literature supports GERD as a risk factor for COPD-exacerbations and a predictor of the 'frequent-exacerbator'-phenotype. CONCLUSIONS Despite the high prevalence of GERD in asthma and COPD, a causal link is lacking. The results of anti-reflux therapy on pulmonary outcome are inconsistent and contradictory. Future studies will need to identify subgroups of asthmatics and COPD patients that may benefit from anti-reflux therapy (nocturnal or silent reflux).
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Affiliation(s)
- C Broers
- Department of Clinical and Experimental Medicine, Translational Research Center for Gastrointestinal Disorders (TARGID), KU Leuven, Leuven, Belgium
| | - J Tack
- Department of Clinical and Experimental Medicine, Translational Research Center for Gastrointestinal Disorders (TARGID), KU Leuven, Leuven, Belgium.,Department of Gastroenterology, Leuven University Hospitals, Leuven, Belgium
| | - A Pauwels
- Department of Clinical and Experimental Medicine, Translational Research Center for Gastrointestinal Disorders (TARGID), KU Leuven, Leuven, Belgium
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37
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Freeman AJ, Hofmekler T, Berauer JP, Palle S. Update in Pediatric Gastroenterology, Hepatology and Nutrition. UPDATE IN PEDIATRICS 2018:267-311. [DOI: 10.1007/978-3-319-58027-2_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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38
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Rogers L. Role of Sleep Apnea and Gastroesophageal Reflux in Severe Asthma. Immunol Allergy Clin North Am 2017; 36:461-71. [PMID: 27401619 DOI: 10.1016/j.iac.2016.03.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Gastroesophageal reflux and obstructive sleep apnea syndrome are conditions that practitioners have been encouraged to evaluate and treat as part of a comprehensive approach to achieving asthma control. In this review, the author looks at the evidence linking these two conditions as factors that may impact difficult-to-control asthma and looks critically at the evidence suggesting that evaluation and treatment of these conditions when present impacts asthma control.
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Affiliation(s)
- Linda Rogers
- Department of Medicine, Mount Sinai-National Jewish Health Respiratory Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1232, New York, NY 10029, USA.
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39
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Abstract
Gastroesophageal reflux disease encompasses a wide spectrum of disorders related to the reflux of gastric contents into the esophagus. Extraesophageal reflux (EER) may be suspected in patients with unexplained chronic cough, pharyngolaryngeal symptoms, and asthma. For physicians, suspected EER is challenging as there is currently no tool that can reliably make a definitive diagnosis. Endoscopic signs are not specific, pharyngeal and proximal reflux monitoring are not reliable, and if distal pH or pH-impedance monitoring can identify patients with abnormal reflux, they cannot predict the response to therapy. Controlled randomized trials have failed to reliably demonstrate any benefit of high-dose proton-pump inhibitors over placebo in patients with laryngeal symptoms, chronic cough, and asthma. Overall, the role of gastroesophageal reflux has been largely overestimated in patients with suspected EER. Especially when proton-pump inhibitors failed to improve symptoms, other diagnosis should be considered, such as functional laryngeal disorders which are probably much more prevalent in these patients than pathologic gastroesophageal reflux.
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Carr TF, Kraft M. Management of Severe Asthma before Referral to the Severe Asthma Specialist. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2017; 5:877-886. [PMID: 28689838 PMCID: PMC5526085 DOI: 10.1016/j.jaip.2017.04.027] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 04/18/2017] [Accepted: 04/20/2017] [Indexed: 12/26/2022]
Abstract
Severe asthma is associated with significant morbidity and can be challenging to assess and control, due to heterogeneity of disease, complexity of diagnosis, and impact of comorbidities. A structured approach to the assessment and management of severe asthma may be helpful to the practicing clinician. First, it is important to confirm a diagnosis of asthma. In patients who are either not responding to treatment, or who require high doses of medication to control symptoms, it is highly possible that disease mimickers or comorbidities are present and can inhibit therapeutic responsiveness. The assessment and management of common comorbidities of asthma may dramatically impact disease control and thus medication requirement. Determining medication adherence and optimizing drug dose and delivery may separate out truly severe asthmatics from those not using medications regularly or properly. Next, although true personalized medicine for severe asthma is not yet realized, for those individuals with severe asthma, phenotypic characteristics of each patient may guide which therapeutic options may be most effective for that patient. Finally, evaluation and management of severe asthma at a referral center can add additional phenotyping, therapeutic, and diagnostic strategies.
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Affiliation(s)
- Tara F Carr
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Ariz.
| | - Monica Kraft
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Ariz
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Fuchs KH, Musial F, Ulbricht F, Breithaupt W, Reinisch A, Babic B, Fuchs H, Varga G. Foregut symptoms, somatoform tendencies, and the selection of patients for antireflux surgery. Dis Esophagus 2017; 30:1-10. [PMID: 28475727 DOI: 10.1093/dote/dox022] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Indexed: 12/11/2022]
Abstract
A large variety of foregut symptoms can occur in patients with gastroesophageal reflux disease (GERD), which can overlap with other disorders such as somatoform disorders and dyspepsia. Due to unclear diagnostic situations, these patients are often not adequately treated. The aim of this study was the evaluation of patients with foregut symptoms, referred for possible antireflux surgery, regarding their relationship with GERD and somatization tendencies based on control data from an unselected population. Symptom evaluation and somatization screening were initiated both in volunteers and in patients with foregut symptoms and GERD. Unselected volunteers from a village population were also evaluated by symptom analysis and for somatisation tendency. In addition, patients with foregut symptoms were diagnosed for GERD, and symptom analysis and psychodiagnostic evaluation were performed. There is no major significant difference in the symptom-spectrum in patients with foregut symptoms, whether they have a proven pathologic acid exposure from GERD or not. The probability for the risk of somatization was 5.6% in the unselected population of nonpatient volunteers (n = 267). In patients with foregut symptoms (n = 750), the probability for the presence of somatoform tendencies was approximately 20%, independent whether these patients had a documented GERD or a normal esophageal acid exposure, implicating further diagnostic work-up for the selection of patients for antireflux surgery. There is a remarkable symptom load and variety in patients with GERD, in patients with foregut symptoms, and in an unselected population of volunteers. There is no difference in the risk for somatization between patients with foregut symptoms and those with documented GERD. Therapeutic decision making especially prior to antireflux surgery requires an awareness of mental and emotional challenges.
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Affiliation(s)
- K-H Fuchs
- AGAPLESION-Markus-Krankenhaus, Department of Surgery, Academic Teaching Hospital
| | - F Musial
- The National Research Center in Complementary and Alternative Medicine, UIT University Tromso, Norway
| | - F Ulbricht
- AGAPLESION-Markus-Krankenhaus, Department of Surgery, Academic Teaching Hospital
| | - W Breithaupt
- AGAPLESION-Markus-Krankenhaus, Department of Surgery, Academic Teaching Hospital
| | - A Reinisch
- AGAPLESION-Markus-Krankenhaus, Department of Surgery, Academic Teaching Hospital.,Department of General Surgery, Goethe University Frankfurt, Frankfurt
| | - B Babic
- AGAPLESION-Markus-Krankenhaus, Department of Surgery, Academic Teaching Hospital
| | - H Fuchs
- Department of General Surgery, University of Cologne, Cologne, Germany
| | - G Varga
- AGAPLESION-Markus-Krankenhaus, Department of Surgery, Academic Teaching Hospital
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Diagnosis and Treatment of the Extraesophageal Manifestations of Gastroesophageal Reflux Disease. Ann Surg 2017; 265:63-67. [PMID: 27455157 DOI: 10.1097/sla.0000000000001907] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To review the clinical presentation, diagnosis, and treatment options available for management of extraesophageal manifestations of gastroesophageal reflux disease (GERD) and to compare the most recent technological advances to the existing guidelines. SUMMARY BACKGROUND DATA Extraesophageal manifestations of GERD include cough, laryngopharyngeal reflux (LPR), and asthma. Recent advances in diagnostic modalities may have outpaced the existing diagnostic and therapeutic clinical guidelines. METHODS We searched the MEDLINE, Cochrane, and Embase databases for articles pertaining to the presentation, diagnosis, and treatment of extraesophageal manifestations of reflux, specifically cough due to reflux, LPR, and asthma due to reflux. Search terms applied to 3 thematic topics: diagnosis, medical treatment, and surgical treatment. We had searched the bibliographies of included studies, yielding a total of 271 articles for full review. We graded the level of evidence and classified recommendations by size of treatment effect, according to the guidelines from the American Heart Association Task Force on Practice Guidelines. RESULTS One hundred twenty-eight articles met criteria for analysis. Our findings show that the diagnosis of cough, LPR, or asthma due to gastroesophageal reflux is difficult, as no criterion standard test exits. Also, patients often present without heartburn or regurgitation typical of GERD. Combined multichannel intraluminal impedance, the pH (MII-pH) monitoring system, and the symptom association probability (SAP) test might distinguish extraesophageal manifestations of reflux from idiopathic chronic cough, laryngitis due to other causes, and atopic asthma. In addition, extraesophageal manifestations of reflux are most effectively diagnosed with a stepwise approach incorporating empiric treatment and antisecretory therapy, combined MII-pH monitoring, and surgical intervention in few selected cases. CONCLUSIONS Recent studies demonstrate the potential diagnostic role of MII-pH monitoring. Surgical intervention provides resolution of extraesophageal symptoms less reliably than typical symptoms when the patient has GERD.
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Hunt EB, Ward C, Power S, Sullivan A, Pearson JP, Lapthorne S, O'Byrne PM, Eustace J, Plant BJ, Maher MM, MacSharry J, Murphy DM. The Potential Role of Aspiration in the Asthmatic Airway. Chest 2017; 151:1272-1278. [PMID: 28300572 DOI: 10.1016/j.chest.2017.03.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 02/10/2017] [Accepted: 03/01/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Many people with asthma remain suboptimally controlled despite current treatments. Reasons include comorbidities that could aggravate asthma, including gastroesophageal reflux. We aimed to investigate whether aspiration occurs in patients with asthma and, if so, does it correlate with asthma control? METHODS Patients had Asthma Control Questionnaire 7 (ACQ-7), fractional exhaled nitric oxide, and spirometry performed to characterize their level of asthma control. Barium swallow with provocation was performed to assess for predisposition to aspiration. Patients underwent bronchoscopic investigation, with BAL pepsin measured as a marker of aspiration. RESULTS Seventy-eight patients stratified by disease severity (Global Initiative for Asthma) into mild (35.8%), moderate (21.7%) and severe (42.3%) were studied. Pepsin was detectable in BAL in 46/78 (58.9%). There were no differences between pepsin levels in patients with different disease severity. Furthermore, no significant associations were seen between pepsin level and measures of asthma control, FEV1, ACQ-7 or exacerbation frequency. Similarly no associations were found with adjustments for smoking history, BMI, proton pump inhibitor use, eosinophil count or IgE. When stratified into eosinophilic or neutrophilic asthmatic populations on the basis of BAL, there was no relationship to detected pepsin concentrations. A positive barium swallow (seen in 33/60 patients) did not correlate with BAL pepsin level and we found no significant association between barium swallow result and ACQ-7, Global Initiative for Asthma, exacerbation frequency or FEV1 using either univariate or multivariate analyses. CONCLUSIONS This study suggests that the importance of aspiration on current asthma symptom control and exacerbation rate may be overstated. However, this study did not address the role of aspiration and future risk of exacerbation.
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Affiliation(s)
- Eoin B Hunt
- Department of Respiratory Medicine, Cork University Hospital, Cork, Ireland; The HRB Clinical Research Facility, University College Cork, Cork, Ireland
| | - Chris Ward
- The Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, England
| | - Stephen Power
- The Department of Radiology, Cork University Hospital, Cork, Ireland
| | - Ashley Sullivan
- The APC Microbiome Institute, Schools of Medicine and Microbiology, University College Cork, Ireland
| | - Jeffrey P Pearson
- The Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, England
| | - Susan Lapthorne
- The APC Microbiome Institute, Schools of Medicine and Microbiology, University College Cork, Ireland
| | - Paul M O'Byrne
- The Michael G DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Joseph Eustace
- The HRB Clinical Research Facility, University College Cork, Cork, Ireland
| | - Barry J Plant
- Department of Respiratory Medicine, Cork University Hospital, Cork, Ireland; The HRB Clinical Research Facility, University College Cork, Cork, Ireland
| | - Michael M Maher
- The Department of Radiology, Cork University Hospital, Cork, Ireland; The HRB Clinical Research Facility, University College Cork, Cork, Ireland
| | - John MacSharry
- The APC Microbiome Institute, Schools of Medicine and Microbiology, University College Cork, Ireland
| | - Desmond M Murphy
- Department of Respiratory Medicine, Cork University Hospital, Cork, Ireland; The HRB Clinical Research Facility, University College Cork, Cork, Ireland.
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Sun S, Cui Z, Zhou M, Li R, Li H, Zhang S, Ba Y, Cheng G. Proton pump inhibitor monotherapy and the risk of cardiovascular events in patients with gastro-esophageal reflux disease: a meta-analysis. Neurogastroenterol Motil 2017; 29. [PMID: 27577963 DOI: 10.1111/nmo.12926] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Accepted: 07/21/2016] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND PURPOSE Proton pump inhibitors (PPIs) are commonly used as potent gastric acid secretion antagonists for gastro-esophageal disorders and their overall safety in patients with gastro-esophageal reflux disease (GERD) is considered to be good and they are well-tolerated. However, recent studies have suggested that PPIs may be a potential independent risk factor for cardiovascular adverse events. The aim of our meta-analysis was to examine the association between PPI monotherapy and cardiovascular events in patients with GERD. METHODS A literature search involved examination of relevant databases up to July 2015 including PubMed, Cochrane Library, EMBASE, and ClinicalTrial.gov, as well as selected randomized controlled trials (RCTs) reporting cardiovascular events with PPI exposure in GERD patients. In addition, the pooled risk ratio (RR) and heterogeneity were assessed based on a fixed effects model of the meta-analysis and the I2 statistic, respectively. KEY RESULTS Seventeen RCTs covering 7540 patients were selected. The pooled data suggested that the use of PPIs was associated with a 70% increased cardiovascular risk (RR=1.70, 95% CI: [1.13-2.56], P=.01, I2 =0%). Furthermore, higher risks of adverse cardiovascular events in the omeprazole subgroup (RR=3.17, 95% CI: [1.43-7.03], P=.004, I2 =25%) and long-term treatment subgroup (RR=2.33, 95% CI: [1.33-4.08], P=.003, I2 =0%) were found. CONCLUSION & INFERENCES PPI monotherapy can be a risk factor for cardiovascular adverse events. Omeprazole could significantly increase the risk of cardiovascular events and, so, should be used carefully.
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Affiliation(s)
- S Sun
- Shenyang Pharmaceutical University, Shenyang, China
| | - Z Cui
- Department of Gastroenterology, General Hospital of Shenyang Military Area, Shenyang, China
| | - M Zhou
- Shenyang Pharmaceutical University, Shenyang, China
| | - R Li
- Shenyang Pharmaceutical University, Shenyang, China
| | - H Li
- Shenyang Pharmaceutical University, Shenyang, China
| | - S Zhang
- Shenyang Pharmaceutical University, Shenyang, China
| | - Y Ba
- Shenyang Pharmaceutical University, Shenyang, China
| | - G Cheng
- Shenyang Pharmaceutical University, Shenyang, China
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Jaimchariyatam N, Haprasert P, Gonchanvit S, Wongtim S. Observational study of omeprazole for gastroesophageal reflux on pulmonary function in adult asthmatics. ASIAN BIOMED 2017. [DOI: 10.5372/1905-7415.0902.379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Abstract
Background
Asthma is a chronic inflammatory disease of airways. Gastroesophageal reflux disease (GERD) is known to be associated with worsening asthma. We hypothesized that treatment of GERD in asthmatics will improve asthma control and quality of life. We reviewed our experience of treatment of GERD in asthmatics in Thailand.
Objectives
To study the effects of omeprazole for treatment of GERD in patients with poorly controlled asthma on pulmonary function tests and asthma control test (ACT) scores.
Methods
This study was conducted at King Chulalongkorn Memorial Hospital between August 2009 and December 2010. Patients with partly controlled and uncontrolled asthma who were found to have GERD by 24 hour esophageal pH monitoring were administered omeprazole 40 mg per day for 8 weeks. Pulmonary function tests and ACT scores before and after treatment were compared at 4-weeks and 8-weeks follow up.
Results
Twenty four patients were included in this study. None of them had asthmatic attacks during the study. After 4 and 8 weeks of omeprazole treatment, the mean FEV1 (2.20 ± 0.64 L, 2.36 ± 0.58 L, respectively) and the mean ACT score (20.82 ± 3.30, 23.00 ± 1.69, respectively) were significantly higher than the pretreatment values (mean FEV1 1.99 ± 0.56 L and ACT score 16.36 ± 3.97) (P < 0.05).
Conclusion
High-dose omeprazole may improve pulmonary function and the level of asthma control in Thai patients with partly controlled or uncontrolled asthma and coexisting GERD.
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Affiliation(s)
- Nattapong Jaimchariyatam
- Division of Pulmonary and Critical Care Medicine , Department of Medicine, Faculty of Medicine , Chulalongkorn University , Bangkok 10330 , Thailand
- Excellence Center for Sleep Disorders , King Chulalongkorn Memorial Hospital, Thai Red Cross Society , Bangkok 10330 , Thailand
| | - Phurin Haprasert
- Division of Pulmonary and Critical Care Medicine , Department of Medicine, Faculty of Medicine , Chulalongkorn University , Bangkok 10330 , Thailand
| | - Sutep Gonchanvit
- Gastrointestinal Motility Research Unit , Division of Gastroenterology, Department of Medicine, Faculty of Medicine , Chulalongkorn University , Bangkok 10330 , Thailand
| | - Somkiat Wongtim
- Division of Pulmonary and Critical Care Medicine , Department of Medicine, Faculty of Medicine , Chulalongkorn University , Bangkok 10330 , Thailand
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Kovesi T. Aspiration Risk and Respiratory Complications in Patients with Esophageal Atresia. Front Pediatr 2017; 5:62. [PMID: 28421172 PMCID: PMC5376561 DOI: 10.3389/fped.2017.00062] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 03/15/2017] [Indexed: 11/27/2022] Open
Abstract
Chronic, long-term respiratory morbidity (CRM) is common in patients with a history of repaired congenital esophageal atresia, typically associated with tracheoesophageal fistula (EA/TEF). EA/TEF patients are at high risk of having aspiration, and retrospective studies have associated CRM with both recurrent aspiration and atopy. However, studies evaluating the association between CRM in this population and either aspiration or atopy have reported conflicting results. Furthermore, CRM in this population may be due to other related conditions as well, such as tracheomalacia and/or recurrent infections. Aspiration is difficult to confirm, short of lung biopsy. Moreover, even within the largest evidence base assessing the association between CRM and aspiration, which has evaluated the potential relationship between gastroesophageal reflux and asthma, findings are contradictory. Studies attempting to relate CRM to prior aspiration events may inadequately estimate the frequency and severity of previous aspiration episodes. There is convincing evidence documenting that chronic, massive aspiration in patients with repaired EA/TEF is associated with the development of bronchiectasis. While chronic aspiration is likely associated with other CRM in patients with repaired EA/TEF, this does not appear to have been confirmed by the data currently available. Prospective studies that systematically evaluate aspiration risk and allergic disease in patients with repaired EA/TEF and document subsequent CRM will be needed to clarify the causes of CRM in this population. Given the prevalence of CRM, patients with repaired EA/TEF should ideally receive regular follow-up by multidisciplinary teams with expertise in this condition, throughout both childhood and adulthood.
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Affiliation(s)
- Thomas Kovesi
- Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
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47
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Baumeler L, Papakonstantinou E, Milenkovic B, Lacoma A, Louis R, Aerts JG, Welte T, Kostikas K, Blasi F, Boersma W, Torres A, Rohde GGU, Boeck L, Rakic J, Scherr A, Tamm M, Stolz D. Therapy with proton-pump inhibitors for gastroesophageal reflux disease does not reduce the risk for severe exacerbations in COPD. Respirology 2016; 21:883-90. [PMID: 26970108 DOI: 10.1111/resp.12758] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Revised: 12/18/2015] [Accepted: 12/18/2015] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND OBJECTIVE Gastroesophageal reflux disease (GERD) symptoms are associated with a higher risk of chronic obstructive pulmonary disease (COPD) exacerbation. We hypothesize that treatment with proton pump inhibitors reduces the risk of exacerbation in patients with stable COPD. METHODS A total of 638 patients with stable COPD for ≥6 weeks, ≥10 pack-years of smoking and Global Initiative for Chronic Obstructive Lung Disease II-IV seeking care in tertiary hospitals in eight European countries in the Predicting Outcome using Systemic Markers in Severe Exacerbations-COPD cohort was prospectively evaluated by us. Comorbidities including associated medical treatment were assessed at baseline, at exacerbation and at biannual visits. Median observation time was 24 months. The primary study outcomes were exacerbation and/or death. RESULTS A total of 85 (13.3%) of COPD patients were on anti-GERD therapy. These patients had higher annual and higher severe exacerbation rates (P = 0.009 and P = 0.002), decreased quality of life (SF-36: activity score P = 0.004, St. George's Respiratory Questionnaire: physical functioning P = 0.013 and social functioning P = 0.007), higher body mass airflow obstruction, dyspnea and exercise capacity index (P = 0.033) and Modified Medical Research Council scores (P = 0.002), shorter 6-min walking distance (P = 0.0004) and a higher adjusted Charlson score (P < 0.0001). Anti-GERD therapy was associated with a shorter time to severe exacerbation (HR 2.05 95% CI 1.37-3.08). Using three multivariable Cox-regression models, this association was independent of the following: (i) adjusted Charlson score and FEV1% predicted (HR 1.91 95% CI 1.26-2.90); (ii) adjusted Charlson score, body mass, airflow obstruction, dyspnea and exercise capacity index and Modified Medical Research Council (HR 1.62 95% CI 1.04-2.54); and (iii) adjusted Charlson score, FEV1% predicted and nine classes of medication for comorbidities (HR 1.63 95% CI 1.04-2.53). CONCLUSION These findings suggest that patients with stable COPD receiving acid-suppressive therapy with proton pump inhibitors remain at high risk of frequent and severe exacerbations.
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Affiliation(s)
- Luzia Baumeler
- Clinic of Pneumology and Respiratory Cell Research, University Hospital, Basel, Switzerland
| | - Eleni Papakonstantinou
- Clinic of Pneumology and Respiratory Cell Research, University Hospital, Basel, Switzerland
| | - Branislava Milenkovic
- Faculty of Medicine, University of Belgrade; Clinic for Pulmonary Diseases, Belgrade, Serbia
| | - Alicia Lacoma
- Department of Microbiology, CIBER Enfermedades Respiratorias, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Renaud Louis
- Department of Pneumology, CHU Liege, GIGAI Research Group, University of Liege, Liege, Belgium
| | - Joachim G Aerts
- Department of Pneumology, Amphia Hospital/Erasmus MC, Breda, The Netherlands
| | - Tobias Welte
- Department of Pneumology, Medizinische Hochschule Hannover, Hannover, Germany
| | | | - Francesco Blasi
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Milan, Italy
| | - Wim Boersma
- Department of Pneumology, Medisch Centrum Alkmaar, Alkmaar, The Netherlands
| | - Antoni Torres
- Department of Pneumology, Hospital Clinic, Barcelona, Spain
| | - Gernot G U Rohde
- Department of Respiratory Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Lucas Boeck
- Clinic of Pneumology and Respiratory Cell Research, University Hospital, Basel, Switzerland
| | - Janko Rakic
- Clinic of Pneumology and Respiratory Cell Research, University Hospital, Basel, Switzerland
| | - Andreas Scherr
- Clinic of Pneumology and Respiratory Cell Research, University Hospital, Basel, Switzerland
| | - Michael Tamm
- Clinic of Pneumology and Respiratory Cell Research, University Hospital, Basel, Switzerland
| | - Daiana Stolz
- Clinic of Pneumology and Respiratory Cell Research, University Hospital, Basel, Switzerland
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Turner AM, Tamasi L, Schleich F, Hoxha M, Horvath I, Louis R, Barnes N. Clinically relevant subgroups in COPD and asthma. Eur Respir Rev 2016; 24:283-98. [PMID: 26028640 DOI: 10.1183/16000617.00009014] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
As knowledge of airways disease has grown, it has become apparent that neither chronic obstructive pulmonary disease (COPD) nor asthma is a simple, easily defined disease. In the past, treatment options for both diseases were limited; thus, there was less need to define subgroups. As treatment options have grown, so has our need to predict who will respond to new drugs. To date, identifying subgroups has been largely reported by detailed clinical characterisation or differences in pathobiology. These subgroups are commonly called "phenotypes"; however, the problem of defining what constitutes a phenotype, whether this should include comorbid diseases and how to handle changes over time has led to the term being used loosely. In this review, we describe subgroups of COPD and asthma patients whose clinical characteristics we believe have therapeutic or major prognostic implications specific to the lung, and whether these subgroups are constant over time. Finally, we will discuss whether the subgroups we describe are common to both asthma and COPD, and give some examples of how treatment might be tailored in patients where the subgroup is clear, but the label of asthma or COPD is not.
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Affiliation(s)
- Alice M Turner
- Clinical and Experimental Medicine, University of Birmingham, Queen Elizabeth Hospital Birmingham, Birmingham, UK Dept of Respiratory Medicine, Birmingham Heartlands Hospital, Birmingham, UK
| | - Lilla Tamasi
- Dept of Pulmonology, Semmelweis University, Budapest, Hungary
| | | | - Mehmet Hoxha
- Service of Allergology and Clinical Immunology, UHC "Mother Teresa", Tirana, Albania
| | - Ildiko Horvath
- Dept of Pulmonology, Semmelweis University, Budapest, Hungary
| | - Renaud Louis
- Respiratory Medicine, CHU Sart-Tilman B35, Liege, Belgium
| | - Neil Barnes
- GlaxoSmithKline, Stockley Park West, Uxbridge, UK
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Naik RD, Vaezi MF. Extra-esophageal gastroesophageal reflux disease and asthma: understanding this interplay. Expert Rev Gastroenterol Hepatol 2015; 9:969-82. [PMID: 26067887 DOI: 10.1586/17474124.2015.1042861] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Gastroesophageal reflux disease (GERD) is a condition that develops when there is reflux of stomach contents, which typically manifests as heartburn and regurgitation. These esophageal symptoms are well recognized; however, there are extra-esophageal manifestations of GERD, which include asthma, chronic cough, laryngitis and sinusitis. With the rising incidence of asthma, there is increasing interest in identifying how GERD impacts asthma development and therapy. Due to the poor sensitivity of endoscopy and pH monitoring, empiric therapy with proton pump inhibitors (PPIs) is now considered the initial diagnostic step in patients suspected of having GERD-related symptoms. If unresponsive, diagnostic testing with pH monitoring off therapy and/or impedance/pH monitoring on therapy, may be reasonable in order to assess for baseline presence of reflux with the former and exclude continued acid or weakly acid reflux with the latter tests. PPI-unresponsive asthmatics, without overt regurgitation, usually have either no reflux or causes other than GERD. In this group, PPI therapy should be discontinued. In those with GERD as a contributing factor acid suppressive therapy should be continued as well as optimally treating other etiologies requiring concomitant treatment. Surgical fundoplication is rarely needed but in those with a large hiatal hernia, moderate-to-severe reflux by pH monitoring surgery might be helpful in eliminating the need for high-dose acid suppressive therapy.
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Affiliation(s)
- Rishi D Naik
- Division of Gastroenterology, Hepatology, and Nutrition, Center for Swallowing and Esophageal Disorders, Digestive Disease Center, Vanderbilt University Medical Center, 1660 TVC, Nashville, TN 37232-5280, USA
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50
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Dirou S, Germaud P, Bruley des Varannes S, Magnan A, Blanc FX. [Gastro-esophageal reflux and chronic respiratory diseases]. Rev Mal Respir 2015; 32:1034-46. [PMID: 26071979 DOI: 10.1016/j.rmr.2015.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Accepted: 03/06/2015] [Indexed: 01/22/2023]
Abstract
Gastroesophageal reflux disease (GERD) frequently occurs in association with chronic respiratory diseases although the casual link is not always clear. Several pathophysiological and experimental factors are considered to support a role for GERD in respiratory disease. Conversely, respiratory diseases and bronchodilator treatment can themselves exacerbate GERD. When cough or severe asthma is being investigated, GERD does not need to be systematically looked for and a therapeutic test with proton pump inhibitors is not always recommended. pH impedance monitoring is now the reference diagnostic tool to detect non acid reflux, a form of reflux for which proton pump inhibitor treatment is ineffective. Recent data have shown a potential role of GERD in idiopathic pulmonary fibrosis and bronchiolitis obliterans following lung transplantation, leading to discussions about the place of surgery in this context. However, studies using pH impedance monitoring are still needed to better understand and manage the association between GERD and chronic respiratory diseases.
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Affiliation(s)
- S Dirou
- Université de Nantes, Nantes 44000, France; Institut du thorax, service de pneumologie, hôpital G. et R. Laënnec, CHU de Nantes, boulevard J.-Monod, 44093 Nantes cedex 1, France
| | - P Germaud
- Institut du thorax, service de pneumologie, hôpital G. et R. Laënnec, CHU de Nantes, boulevard J.-Monod, 44093 Nantes cedex 1, France
| | - S Bruley des Varannes
- Institut des maladies de l'appareil digestif, service d'hépatogastroentérologie et assistance nutritionnelle, CHU de Nantes, Nantes 44093, France; DHU2020 médecine personnalisée des maladies chroniques, Nantes 44000, France
| | - A Magnan
- Université de Nantes, Nantes 44000, France; Institut du thorax, service de pneumologie, hôpital G. et R. Laënnec, CHU de Nantes, boulevard J.-Monod, 44093 Nantes cedex 1, France; DHU2020 médecine personnalisée des maladies chroniques, Nantes 44000, France; Inserm, UMR1087, institut du thorax, Nantes 44093, France; CNRS, UMR 6291, Nantes 44000, France
| | - F-X Blanc
- Université de Nantes, Nantes 44000, France; Institut du thorax, service de pneumologie, hôpital G. et R. Laënnec, CHU de Nantes, boulevard J.-Monod, 44093 Nantes cedex 1, France; DHU2020 médecine personnalisée des maladies chroniques, Nantes 44000, France; Inserm, UMR1087, institut du thorax, Nantes 44093, France; CNRS, UMR 6291, Nantes 44000, France.
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