슬라이드 1

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1 상부위장관질환약물처방요령 성균관대학교의과대학삼성서울병원소화기내과

2 위식도역류질환 성균관대학교의과대학삼성서울병원소화기내과

3 Prevalence of GERD in health checkup Erosive esophagitis Reflux symptoms 7% 3% 7% 83%

4 말하지않는사람도많습니다.

5 GERD 빈도는계속증가할것인가? Prevalence of GERD in Korea (2) (1)

6 Pathophysiology is very complex Impaired mucosal defence Impaired LOS (smoking, fat, alcohol) transient LOS relaxations basal tone bile reflux Bile and pancreatic enzymes salivary HCO 3 H + Pepsin oesophageal clearance of acid (lying flat, alcohol, coffee) Hiatus hernia acid output (smoking, coffee) intragastric pressure (obesity, lying flat) gastric emptying (fat) de Caestecker, BMJ 2001; 323:736 9 Johanson, Am J Med 2000; 108(Suppl 4A): S99 103

7 PPI 혹은 P-CAB 으로잘조절됩니다. H 2 RA Cimetidine, Ranitidine, Famotidine, Nizatidine, Roxatidine 1 st PPI Omeprazole, Lansoprazole, Pantoprazole 2 nd PPI Rabeprazole, Esomeprazole, Dexlansoprazole, Ilaprazole P-CAB Revaprazan, Vonoprazan, Tegoprazan (K-CAB)

8 PPIs Conversion to a reactive form Irreversible binding to the external surface of acid pump Need to stimulate proton pump P-CAB Directly binds to K+ Binding domain at resting and stimulated state Reversible binding No need to stimulate proton pump

9 Why PPI/P-CAB is superior to H2RA? Factors for successful acid suppression Degree of acid suppression (ph < 4) Time of acid suppression during 24 hours Duration of treatment Patients healed after 8 weeks (%) Duration intragastric ph>4 (hours) Bell. Gut 1992;

10 H2RA 만드시던분이 PPI 를드시더니

11 Rapid tolerance of H 2 RA Lachman. Am J Gastroenterol 2000;95:57-61

13 PPI 가좋기는하지만 환자의만족도는의사보다못합니다. The proportion of very satisfied or well controlled is higher by doctors assessment (blue bar) than the patients assessment (green bar). ReQuest TM -GI questionnaire

14 Patients without heartburn (%) PPI failure 의상당수는야간증상입니다. 80 PPI H 2 RA PPI Failure Time in weeks Chiba. Gastroenterology 1997;112:

15 야간증상에대한쉬운설명 - (1) 밭을매면속이쓰리다. (2) 직립보행

16 어떻게해석하시겠습니까?

17 치료중단후증상재발률은 ERD 와 NERD 에서차이가없으므로모두대책이필요하다. Patients in symptomatic remission (%) patients without esophagitis patients with esophagitis Time since treatment cessation (months) 25% 10% Carlsson et al 1998b

18 증상이재발하면원래병원을찾을까요? 두번이상재발하면 동일병원방문은 40% 정도

19 Various methods of maintenance Continuous maintenance (every day or every other day) Continuous maintenance 2-4 weeks 2-4 weeks 2-4 weeks 2-4 weeks Intermittent s s s s on demand s Resolution of symptoms with initial therapy s s s s s Talley N et al 2000 (Abstract)

20 P-CAB for on-demand therapy Umezawa. Digestion 2018

21 33 tablets (median)/24 weeks Umezawa. Digestion 2018

22 On demand vs every other day

23 Threshold therapy 는무엇인가? For 'threshold' therapy, patients gradually increase the interval between medications (for example, to every second or third day) as long as symptoms do not recur. The patient titrates the medication down to a frequency that still maintains adequate control of symptoms. This is different from on-demand therapy where each time the patient waits for recurrence of symptoms. Zancy. Aliment Pharmacol Ther 2005;21:

25 3 일에한번드시고편 ~~~ 하게사세요.

26 7-10 일에한번먹는다. 약이아주좋다.

27 Goals of long-term treatment of GERD 증상 조절 식도염 healing 유지 합병증 예방

28 지속적투약이필요한환자도있습니다. 수년전부터위식도역류질환으로간헐적으로 PPI 복용하고있던분의 2016 년내시경 매년검사와간헐적투약을하고있었으며 obstruction 증상으로 2019 년의뢰됨

29 History + Endoscopy (establish Dx, Sx pattern, & Ds severity) 60% 40% IT or ODT 20% MT Endoscopy Mild EE or NERD Severe EE, stricture, or BE # Attacks/yr + 3 or > 3 PPI Response + rapid or slow Age + young or elderly Comorbidity Drugs + no or yes Bardhan KD. Am J Gastroenterol 2003;98:S40

30 좁아질것같으니약좀드세요. 평생.

31 Lifestyle modifications - only for selected patients Grade B: Weight loss should be advised for overweight or obese patients with esophageal GERD syndromes. Grade B: Elevation of the head of the bed for selected patients who are troubled with heartburn or regurgitation when recumbent. Other lifestyle modifications, including avoiding late meals, avoiding specific foods, or avoiding specific activities should be tailored to the circumstances of the individual patient. Grade Insuff: Broadly advocating lifestyle changes for all (as opposed to selected) patients with GERD. AGA position statement. Gastroenterology 2008;135:

32 헬리코박터파이로리 성균관대학교의과대학삼성서울병원소화기내과

33 1 차제균치료처방예 (100/100)

34 환자설명서 (endotoday.com) 2017년말까지는소화성궤양이나위암환자에서만헬리코박터치료가가능했습니다. 그런데 2018년 1월 1월부터소화성궤양이나암환자가아니더라도제균치료가가능하게되었습니다. 많이비싸지는않지만 " 약값전액을환자가부담토록함 " 으로결정되었습니다. 원하시면제균치료를처방해드릴수있습니다. 소화성궤양을어느정도예방할수있으며, 아직논란이있지만위암발생률이낮아진다는일부주장이있기때문입니다.

35 환자설명서 (endotoday.com) 두종류의항생제와한종류의위산분비억제제를 1주투약합니다. 주로항생제때문에설사등위장장애나알러지와같은부작용이가능합니다만개인차는큽니다. 심하면약을중단해야하겠지만경한위장장애만있는경우는가능한모든약을정해진대로전부복용하시기바랍니다. 제균성공률은 80% 전후입니다. 치료가잘되었는지확인하기위하여약 8 주후호기검사를합니다. 계획 : 제균치료 (100/100) + 8주후호기검사

36 말로설명한후그림으로한번더설명

37 헬리코박터제균치료도중혈변. 대장내시경에서큰용종발견 (F/56)

38 3 제요법의제균율은 70-75% 선입니다.

39 항생제내성이주요원인이지만우리나라의내성률이유난히높은것도아닙니다. Kim, et al. WJGPT 2015

40 항생제 내성률 Clarithromycin 17.8% Metronidazole 29.5% Amoxicillin 9.5% Tetracyclin 0% Levofloxacin 37.0% Ciprofloxacin 37.0% Helicobacter. 2019;24:e12592

41 Helicobacter. 2019;24:e12592

42 가이드라인은이렇게언급하고있습니다. Treatment of 2009 Treatment of st line PPI (standard dose bid)+clarithromycin (0.5 g bid)+amoxicillin (1 g bid) for 1 or 2 weeks 2 nd line PPI (standard dose bid)+metronidazole (0.5 g tid)+bismuth (120 mg qid)+tetracycline (0.5 g qid) for 1 or 2 weeks Therapy for a week or two weeks issue is not Yet clear, so it is need to clarify the treatment duration through evidence of current or future. 1 st line PPI (standard dose bid)+clarithromycin (0.5 g bid) +amoxicillin (1 g bid) for 1 or 2 weeks High clarithromycin resistance PPI (standard dose bid)+metronidazole (0.5 g tid) +bismuth (120 mg qid)+tetracycline (0.5 g qid) for 1 or 2 weeks 2 nd line If the triple therapy fail as 1 st line PPI (standard dose bid)+metronidazole (0.5 g tid) +bismuth (120 mg qid)+tetracycline (0.5 g qid) fo r 1 or 2 weeks If the quadruple therapy fail as 1 st line Combination of two /more antibiotics without prior exposures experiences

43 Korean J Gastroenterol 2013;62:3-26

44 Korean J Gastroenterol 2013;62:3-26

45 4 제요법을초치료로사용할수있는가?

46 Kim. Korean J Gastroenterol 2013

47 Ten day sequential therapy PPI + Amoxicillin PPI b.i.d + Clarithromycin + Nitroimidazole (metronidazole, tinidazole) 5 days 5 days 1. Clarithromycin 포함삼제요법은위강내세균밀도가낮을때높은제균율을획득할수있다. 2. H.pylori 는 clarithromycin 의 efflux channel( 유출채널 ) 을만들어항생제를빠르게세균밖으로이동시켜저항성을가지나, amoxicillin 초기사용하여, 세균의세포벽을약화, 유출채널의발달저해한다.

48 Kim. Korean J Gastroenterol 2013

49 2 차제균치료처방예

50 2 차제균치료에대한질문 1. Bismuth 의경우에는데졸정 1tab = 300mg 입니다. 120mg qid 로어떻게처방을내면되는지요? 2. 4제요법은 7~14일이라고가이드라인에되어있는데, 심평원기준은며칠로처방해야하는지요? 3. 드러그인포에 bisthmus 는 "tetracycline 의흡수를저해할수있으므로병용투여하지않는다 ", "2시간이상의간격을두고투여한다 " 라고되어있습니다. bisthmus 는 qid, tetracycline도 qid 인데, 4제요법각각의약복약시간을어떻게시켜야하는지요? EndoTODAY 애독자질문

51 2 차치료설명의실제와데놀의부작용

52 [ 질문 ] 1 차약을하루밖에먹지못함

53 [ 답변 ] 1 차약을하루밖에먹지못함

54 증례검토 성균관대학교의과대학삼성서울병원소화기내과

55 가족모임후에알수없는복통과더불어, 심근경색처럼명치끝이답답하고, 체기도지속되며, 등통증, 허리통증식은땀등여러복합적인증상으로응급실을내원하여, 심전도검사및혈액검사를시행하였음에도 역류성식도염이라고추정진단을받고수액치료후에집에돌아왔으나 통증은계속사라지지않고, 참을수없이고통스러워인터넷으로소화기내과이준행교수님의진료를예약하고외래에서진료를보았는데, 교수님께서위내시경과복부CT 및혈액검사를해보자고하셔서검사후결과를들었는데.

56 예상과다른질병이었습니다. 교수님께서진단하시길, 위쪽은병변없이깨끗하나담석의위치가애매하므로담석을전문으로하시는선생님의진료를권유하셔서 절차대로소화기내과를담석교수님을거쳐, 외과최동욱교수님의진료를최종적으로받게되었습니다 ( 중략 ) 정확한진단과치료, 그리고의료진의입장보다환자를우선적으로배려해주신외과최XX 교수님, 내과이준행교수님, 병실김XX 간호사님께다시한번감사드립니다.

57 역류성식도염으로오인되었던 biliary colic

58 수년동안 GERD 로치료받았는데계속불편하다는환자입니다. GERD 맞습니까? PPI 먹어도

59 Achalasia

60 맺음말 치료에앞서정확한진단이중요합니다. 상황별표준처방이가장효과적입니다.

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<B0E6C8F1B4EBB3BBB0FAC0D3BBF3B0ADC1C E687770> 개원의와함께하는임상강좌 2011 역류성식도질환제대로이해하기 Division of Gastroenterology, Department of Internal Medicine, Kyung Hee University College of Medicine, Seoul, Korea Jae-Young Jang, M.D., PhD. 개원의와함께하는임상강좌 2011 109 최신치료