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Journal Club: “Role of Gastroesophageal Reflux Symptoms in Exacerbations of COPD”

Journal Club: “Role of Gastroesophageal Reflux Symptoms in Exacerbations of COPD”. October 19, 2006 Christopher Ingelmo Anil J. Trindade J. Hunter Young. Results:. GERD (+) = “Weekly symptomatic GERD over the past year” based on the Mayo Survey.

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Journal Club: “Role of Gastroesophageal Reflux Symptoms in Exacerbations of COPD”

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  1. Journal Club:“Role of Gastroesophageal Reflux Symptoms in Exacerbations of COPD” October 19, 2006 Christopher Ingelmo Anil J. Trindade J. Hunter Young

  2. Results: GERD (+) = “Weekly symptomatic GERD over the past year” based on the Mayo Survey.

  3. Comparison of Exacerbation Type • GERD (+) patients had significantly increased rates of COPD exacerbations (p=0.02), hospitalizations (p=0.007), ER visits (p=0.005), unscheduled clinic appointments (p=0.01) and antibiotic use (p=0.01) compared to GERD (-) patients. • There was no significant difference in corticosteroid use between GER+ and GER- patients.

  4. Patient Demographics: There are no statistically significant differences between the GER+ and GER- groups in terms of age, gender, smoking status, severity of airway obstruction, BMI or coffee and/or EtOH use.

  5. Use of GERD-related Pharmacotherapy: • The majority of patients (61/86) were taking an anti-reflux medicine. • A third of the patients were on combination therapy. • A significantly greater amount of patients taking antacids had GER symptoms weekly.

  6. Break it down. • Trend toward increased number of COPD exacerbations in GER+ patients regardless of reflux pharmacotherapy. • Non-significant trend toward increased COPD exacerbations in GER+ patients, irrespective of severity of airway obstruction. • Trend toward increased COPD exacerbations in those with GER+ weekly symptoms, irrespective of smoking status.

  7. Discussion: Were the Aims of the study Met?: a) Demonstrate prevalence of symptomatic GERD in the sampled population (those with COPD) i) 36% of COPD patients had GER Sx compared to general US population of 14-19% b) Determine if an epidemiologic association between GER symptoms and exacerbations of COPD existed i) Overall there was a significantly increased rate of COPD exacerbations in those with GER+ symptoms compared to those without (p=0.02) ii) When controlled for severity of airway disease, non-signif trend toward increased exacerbations in those with GER+ symptoms

  8. Does GERD cause increased COPD Exacerbations? Association vs. Causality • Temporality cause precedes effect • Dose Response • Reversibility  Lower disease rates with reduced exposure. • Consistency  repeatedly observed in different people, places, circumstances and time. • Biologic plausibility • Specificity one cause leads to one effect • Analogy  Cause-effect relationshipestablished for similar exposure or disease. • Strength of the Association large relative risk …Limitations of a Cross-sectional / Prevalence Study…

  9. Precautions: • Recall Bias • Confounding Bias a) Risk factors for GERD  age, BMI, caffeine/EtOH b) Can GERD-therapies cause exacerbations? c) Can COPD-therapies cause GERD? “Oral Corticosteroids Increase Esophageal Acid Contact Times in Patients with Stable Asthma.” Chest. 2002;121:625-634.)

  10. Conclusion • “Findings suggest a possible modifiable risk factor in exacerbations of COPD.” • Cross sectional study is an easy way to show an association between a risk factor and a disease. What’s Next? • Longitudinal study to help show causality

  11. References: • Rascon-Aguilar, et al. “ Role of Gastroesophageal Reflux Symptoms in Exacerbations of COPD.” Chest 2006; 130: 1096-1101. • Lazenby, etal. “Oral Corticosteroids Increase Esophageal Acid Contact Times in Patients with Stable Asthma.” Chest 2002; 121: 625-634. • Fletcher RW, Fletcher SW. “Clinical Epidemiology: The Essentials. 4th Edition” Lippincott Williams & Wilkins. 2005

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