Evidence-Based GI Doc

Philip Schoenfeld, MD, MSEd, MSc (Epi). Gastroenterologist. Evidence-Based GI #EBGI

[Evidence-Based GI Doc @EBGIdoc]

@LindaNguyenMD @ScrubsNHeels @DCharabaty @IBD_Afzali @kehutchins77 @MN_GIMD @MccutchenDr @drfolamay @AasmaShaukatMD @JChristieMD …. Is your “husband” part of the package, too 😱

[Evidence-Based GI Doc @EBGIdoc]

@CarlKayMD @ABIMcert Congrat

[Siew Ng @Siew_C_Ng]

An award that represents the labour of love for science, perseverance and belief, plus the bonus of a dream team.

[Evidence-Based GI: An ACG Publication (EBGI) @ACG_EBGI]

In #EBGI: On-Demand Vonoprazan for Non-Erosive Reflux Disease Symptoms: A New Option
Reviewer: Christopher Vélez, MD

📖 https://t.co/NYvkp1Cqvo
🔊 https://t.co/f1y2QKK4DQ

@AmCollegeGastro @Chris_Velez_MD

[Evidence-Based GI Doc @EBGIdoc]

@aferoz19 @umer446 @ScopingSundays @ACG_EBGI @CamilleLupianez @AmCollegeGastro @BilalMohammadMD @AhmadBazarbashi @RobertoSimonsMD @vaibhav_manu @rmulkimd @LizzieAbyMD @AdvaniRashmiMD @AimenKhanMD @MouhandMD @DavidDiehlMD @SanchezLunaMD @AdamKichlerDO @sachdevmd @SumantInamdar @ShyamTMD @QuinTheLiuMD @KKadkhodayan @MetabolicEndo @AmJGastro @rjsealock @EndoscopyOthman @d21loren @tberzin @Boston_Endo @MSawhneyMD @abdul_kouanda @SriGaddamMD @shailsingh @NorioFukamiMD Other database studies showing that PPIs are "ASSOCIATED" with different disorders (e.g. dementia) are really simply demonstrating that "sicker" people are more likely to be prescribed PPI (for whatever reason) compared to "healthier" people with fewer baseline medical problems

[Evidence-Based GI Doc @EBGIdoc]

@aferoz19 @umer446 @ScopingSundays @ACG_EBGI @CamilleLupianez @AmCollegeGastro @BilalMohammadMD @AhmadBazarbashi @RobertoSimonsMD @vaibhav_manu @rmulkimd @LizzieAbyMD @AdvaniRashmiMD @AimenKhanMD @MouhandMD @DavidDiehlMD @SanchezLunaMD @AdamKichlerDO @sachdevmd @SumantInamdar @ShyamTMD @QuinTheLiuMD @KKadkhodayan @MetabolicEndo @AmJGastro @rjsealock @EndoscopyOthman @d21loren @tberzin @Boston_Endo @MSawhneyMD @abdul_kouanda @SriGaddamMD @shailsingh @NorioFukamiMD Personally, I rely on the COMPASS RCT, which is the only large (thousands of patients), double-blind, placebo-controlled RCT with 4 year + follow-up. Found that increase in enteric infections (e.coli diarrhea) was only increased adverse event vs placebo with PPIs

[Evidence-Based GI Doc @EBGIdoc]

@aferoz19 @umer446 @ScopingSundays @ACG_EBGI @CamilleLupianez @AmCollegeGastro @BilalMohammadMD @AhmadBazarbashi @RobertoSimonsMD @vaibhav_manu @rmulkimd @LizzieAbyMD @AdvaniRashmiMD @AimenKhanMD @MouhandMD @DavidDiehlMD @SanchezLunaMD @AdamKichlerDO @sachdevmd @SumantInamdar @ShyamTMD @QuinTheLiuMD @KKadkhodayan @MetabolicEndo @AmJGastro @rjsealock @EndoscopyOthman @d21loren @tberzin @Boston_Endo @MSawhneyMD @abdul_kouanda @SriGaddamMD @shailsingh @NorioFukamiMD No increase in side effects vs placebo in RCTs. Per prescribing info provided with meds, the list of POSSIBLE safety concerns is same as PPIs. Important to remember-those PPI safety concerns come from epidemiologic database studies that can't fully account for confounders

[Evidence-Based GI Doc @EBGIdoc]

@AimenKhanMD @CamilleLupianez @ScopingSundays @ACG_EBGI @umer446 @AmCollegeGastro @BilalMohammadMD @AhmadBazarbashi @RobertoSimonsMD @vaibhav_manu @rmulkimd @LizzieAbyMD @AdvaniRashmiMD @MouhandMD Unfortunately, this varies a LOT. Key is that your faculty should be working with pharmacy to make sure vonoprazan is available. Situation is similar to 1989 when PPIs first became available and some hospitals lagged and only provided H2RAs for a couple of years

[Evidence-Based GI Doc @EBGIdoc]

@CamilleLupianez @umer446 @ScopingSundays @ACG_EBGI @AmCollegeGastro @BilalMohammadMD @AhmadBazarbashi @RobertoSimonsMD @vaibhav_manu @rmulkimd @LizzieAbyMD @AdvaniRashmiMD @AimenKhanMD @MouhandMD @DavidDiehlMD @SanchezLunaMD @AdamKichlerDO @sachdevmd @SumantInamdar @ShyamTMD @QuinTheLiuMD @KKadkhodayan @MetabolicEndo @AmJGastro @rjsealock @EndoscopyOthman @d21loren @tberzin @Boston_Endo @MSawhneyMD @abdul_kouanda @SriGaddamMD @shailsingh @NorioFukamiMD @amitbhattMD @SiddikiGI @JohnVargoMD @drsethinyc @ColonDocUMMH @AlysonMJohnson @AnotherPatelMD @NCosgroveMD @DennisYangMD @MItaniMD @clivejmiranda Esophageal testing will definitively distinguish inadequate acid suppression vs functional heartburn, but availability of esophageal testing is limited in many areas of US.

[Evidence-Based GI Doc @EBGIdoc]

@CamilleLupianez @umer446 @ScopingSundays @ACG_EBGI @AmCollegeGastro @BilalMohammadMD @AhmadBazarbashi @RobertoSimonsMD @vaibhav_manu @rmulkimd @LizzieAbyMD @AdvaniRashmiMD @AimenKhanMD @MouhandMD @DavidDiehlMD @SanchezLunaMD @AdamKichlerDO @sachdevmd @SumantInamdar @ShyamTMD @QuinTheLiuMD @KKadkhodayan @MetabolicEndo @AmJGastro @rjsealock @EndoscopyOthman @d21loren @tberzin @Boston_Endo @MSawhneyMD @abdul_kouanda @SriGaddamMD @shailsingh @NorioFukamiMD @amitbhattMD @SiddikiGI @JohnVargoMD @drsethinyc @ColonDocUMMH @AlysonMJohnson @AnotherPatelMD @NCosgroveMD @DennisYangMD @MItaniMD @clivejmiranda Dilemma is because you differentiate between inadequate acid suppression and functional heartburn with: (a) empiric trial of vonoprazan, which greatly minimizes acid production-much better than PPI bid; or (b) do Bravo/manometry/24hr pH testing?

[Evidence-Based GI Doc @EBGIdoc]

@CamilleLupianez @umer446 @ScopingSundays @ACG_EBGI @AmCollegeGastro @BilalMohammadMD @AhmadBazarbashi @RobertoSimonsMD @vaibhav_manu @rmulkimd @LizzieAbyMD @AdvaniRashmiMD @AimenKhanMD @MouhandMD @DavidDiehlMD @SanchezLunaMD @AdamKichlerDO @sachdevmd @SumantInamdar @ShyamTMD @QuinTheLiuMD @KKadkhodayan @MetabolicEndo @AmJGastro @rjsealock @EndoscopyOthman @d21loren @tberzin @Boston_Endo @MSawhneyMD @abdul_kouanda @SriGaddamMD @shailsingh @NorioFukamiMD @amitbhattMD @SiddikiGI @JohnVargoMD @drsethinyc @ColonDocUMMH @AlysonMJohnson @AnotherPatelMD @NCosgroveMD @DennisYangMD @MItaniMD @clivejmiranda Or is inadequate therapeutic response to PPI because patient has functional heartburn (hypersensitive esophagus due to brain-gut dysfunction) and would be better treated with low-dose tri-cyclic antidepressants?

[Evidence-Based GI Doc @EBGIdoc]

@CamilleLupianez @umer446 @ScopingSundays @ACG_EBGI @AmCollegeGastro @BilalMohammadMD @AhmadBazarbashi @RobertoSimonsMD @vaibhav_manu @rmulkimd @LizzieAbyMD @AdvaniRashmiMD @AimenKhanMD @MouhandMD @DavidDiehlMD @SanchezLunaMD @AdamKichlerDO @sachdevmd @SumantInamdar @ShyamTMD @QuinTheLiuMD @KKadkhodayan @MetabolicEndo @AmJGastro @rjsealock @EndoscopyOthman @d21loren @tberzin @Boston_Endo @MSawhneyMD @abdul_kouanda @SriGaddamMD @shailsingh @NorioFukamiMD @amitbhattMD @SiddikiGI @JohnVargoMD @drsethinyc @ColonDocUMMH @AlysonMJohnson @AnotherPatelMD @NCosgroveMD @DennisYangMD @MItaniMD @clivejmiranda Vonoprazan is FDA-approved for NERD. Presents a very interesting dilemma when patient has heartburn symptoms and EGD shows normal esophagus and patient gets only partial/sub-therapeutic improvement with PPI. Is inadequate response due to inadequate acid suppression?

[Evidence-Based GI Doc @EBGIdoc]

@CamilleLupianez @ScopingSundays @ACG_EBGI @umer446 @AmCollegeGastro @BilalMohammadMD @AhmadBazarbashi @RobertoSimonsMD @vaibhav_manu @rmulkimd @LizzieAbyMD @AdvaniRashmiMD @AimenKhanMD @MouhandMD This is not FDA-approved use of vonoprazan, but will be much easier (in the future) if we simply give 20mg oral vonoprazan to ED patients with melena as opposed to starting IV PPI bolus + IV PPI continuous infusion

[Evidence-Based GI Doc @EBGIdoc]

@CamilleLupianez @ScopingSundays @ACG_EBGI @umer446 @AmCollegeGastro @BilalMohammadMD @AhmadBazarbashi @RobertoSimonsMD @vaibhav_manu @rmulkimd @LizzieAbyMD @AdvaniRashmiMD @AimenKhanMD @MouhandMD Although no head-to-head comparisons in healthy individuals (much less patients with gi bleeds), 20 mg vonoprazon oral is likely more potent at increasing gastric pH and would do it more rapidly based on pharmacology.

[Evidence-Based GI Doc @EBGIdoc]

@CamilleLupianez @ScopingSundays @ACG_EBGI @umer446 @AmCollegeGastro @BilalMohammadMD @AhmadBazarbashi @RobertoSimonsMD @vaibhav_manu @rmulkimd @LizzieAbyMD @AdvaniRashmiMD @AimenKhanMD @MouhandMD This raises gastric pH which minimizes conversion of pepsinogen to pepsin and may help platelet function if pH increases enough. Facilitates clot integrity and reduces recurrent bleeding

[Evidence-Based GI Doc @EBGIdoc]

@CamilleLupianez @ScopingSundays @ACG_EBGI @umer446 @AmCollegeGastro @BilalMohammadMD @AhmadBazarbashi @RobertoSimonsMD @vaibhav_manu @rmulkimd @LizzieAbyMD @AdvaniRashmiMD @AimenKhanMD @MouhandMD At time of EGD, if clean-based ulcer, then stop IV PPI. If adherent clot or visible vessel/active bleeding requiring hemostasis, then continue IV PPI

[Evidence-Based GI Doc @EBGIdoc]

@CamilleLupianez @ScopingSundays @ACG_EBGI @umer446 @AmCollegeGastro @BilalMohammadMD @AhmadBazarbashi @RobertoSimonsMD @vaibhav_manu @rmulkimd @LizzieAbyMD @AdvaniRashmiMD @AimenKhanMD @MouhandMD When patient presents with melena or hemetemesis (especially if no reason to suspect esophageal varices), standard is to start 80mg pantoprazole iv bolus + 8mg/hr pantoprazole continuous infusion. This reduces recurrent bleeding if adherent clot has already formed.

[Evidence-Based GI Doc @EBGIdoc]

@umer446 @ScopingSundays @ACG_EBGI @CamilleLupianez @AmCollegeGastro @BilalMohammadMD @AhmadBazarbashi @RobertoSimonsMD @vaibhav_manu @rmulkimd @LizzieAbyMD @AdvaniRashmiMD @AimenKhanMD @MouhandMD @lukens_f @LionelSDSouza @PeterDraganov @doumitb @SkipKrafftMD @AliAbbasMD @neilRsharmaMD @sushilahlawat1 @iGUT_Houston @tr_levin @SultanMahmoodMD @KiwanGIDoc @clivejmiranda @HarshitKharaMD @JennPhanMD @drKumarGI @NikhilKumtaMD @waqmd @alhaddad_mo @gastrowala @gurutrikumd @RajeshKris @ReemSharaiha Although this has been helpful in the past, it's now a bit outdated based on new ACG Guideline on H.pylori tx (sept 2024). Clarithromycin-resistance has increased throughout the US. Don't use clarithromycin-based tx unless you have antibiotic sensitivities

[Evidence-Based GI Doc @EBGIdoc]

@umer446 @ScopingSundays @ACG_EBGI @CamilleLupianez @AmCollegeGastro @BilalMohammadMD @AhmadBazarbashi @RobertoSimonsMD @vaibhav_manu @rmulkimd @LizzieAbyMD @AdvaniRashmiMD @AimenKhanMD @MouhandMD Remember-the new ACG Guideline on H.pylori treatment recommends AGAINST using any clarithromycin-based therapy UNLESS you have PCR of h.pylori strain with specific antibiotic sensitivities (which is rarely done). Bottom Line: stay away from clarithromycin-based tx.