Skip to main content
Volume 3, No 2 - Spring 2003

Volume 3, No 2 - Spring 2003

Table of Contents

Optimizing Medical Therapy for Gastroesophageal Reflux Disease: State of the Art Treatment Update
Potential interventions for gastroesophageal reflux disease include lifestyle modifications, antacids, mucosal protectants, prokinetic (promotility) agents, H2 receptor antagonists (H2RAs) and, the agents of choice in 2003, proton pump inhibitors (PPIs). This article reviews the current state of the art in use of these agents. Lifestyle changes, though sound in their intent and in many cases based on solid laboratory research, can today be considered only adjuncts to pharmacologic therapy. The mainstay of pharmacologic therapy in 2003 is antisecretory therapy. Both H2RAs and PPIs inhibit acid secretion and raise intragastric pH. H2RAs only block one receptor, have limited effect on acid reduction, and are relatively weak inhibitors of meal-stimulated acid secretion. PPIs provide superior control of intragastric pH over a 24-hour period compared with H2RAs and effect greater symptom relief and healing. [Rev Gastroenterol Disord. 2003;3(2):59–69]
Registered Nurse-Administered Propofol Sedation for Upper Endoscopy and Colonoscopy: Why? When? How? Treatment Update
Propofol for sedation during gastrointestinal endoscopic procedures has been associated with improved patient satisfaction relative to combinations of meperidine and midazolam. Delivery of propofol by registered nurses has been shown to be more cost-effective than administration by anesthesiologists or nurse anesthetists. Here, the authors review their experience with nurse-administered propofol sedation (NAPS) at their institutions (a hospital endoscopy unit in a tertiary medical center and an ambulatory surgery center). Endoscopic procedures for which NAPS is (or is not) recommended are listed, and a profile of patients for whom NAPS is contraindicated is given. Steps toward the development of programs and acquisition of training in NAPS are recommended; these include determining what state, local, and institutional laws apply to propofol administration; developing a written protocol; and instituting a training program that proceeds from observation to supervised administration to independent administration of propofol, with appropriate monitoring of safety records. Experience with NAPS using bolus titration (dosage, timing, coadministration with other agents) is detailed, and proper patient monitoring is discussed. NAPS is in its infancy, but this method of sedation shows considerable promise for improving patient satisfaction with, and thereby the reputation of, endoscopic procedures. [Rev Gastroenterol Disord. 2003;3(2):70–80]
The State of the Art in the Management of Inflammatory Bowel Disease Treatment Update
Ulcerative colitis (UC) and Crohn’s disease (CD), collectively known as inflammatory bowel disease (IBD), afflict an estimated one million Americans and produce symptoms that impair quality of life and ability to function. Progress in IBD management strategies has led to optimized approaches for achieving the two primary clinical goals of therapy: induction and maintenance of remission. Although surgery is indicated to treat refractory disease or specific complications, pharmacotherapy is the cornerstone of IBD management. The efficacy of aminosalicylates for induction of remission in mild to moderate UC and CD is well established, as is their role for maintenance of remission in UC. The sulfa-free mesalamine formulation offers an adverse effect profile similar to that of placebo, enabling the administration of higher, more effective doses. Although corticosteroids provide potent anti-inflammatory effects, their benefits are countermanded by the risk of intolerable and serious adverse effects, and they are ineffective for maintenance therapy. Other agents effective in inducing or maintaining remission are azathioprine, 6-mercaptopurine, infliximab, cyclosporine, methotrexate, and antibiotics. Ongoing clinical trials of experimental therapies will generate new tools for IBD treatment. Currently, a broad range of options allows physicians to tailor treatment to each patient’s needs and preferences. Such considerations are essential for maximizing adherence to therapy. [Rev Gastroenterol Disord. 2003;3(2):81–92]
Pegylated Interferon Plus Ribavirin for the Treatment of Chronic Hepatitis C New Drug Review
Peginterferon alfa-2a and peginterferon alfa-2b have been approved for the treatment of chronic hepatitis C virus (HCV) infection in adults who have compensated liver disease and have not been previously treated with interferon alfa. Peginterferon alfa-2a and peginterferon alfa-2b have also been approved for use in combination with ribavirin as therapy for these adults. Combining peginterferon alfa-2a or alfa-2b with ribavirin produces better activity against HCV than either drug alone. Interferon works by binding to specific receptors on the cell surface that initiate a complex cascade of protein-protein interactions leading to rapid activation of gene transcription. The effects of this interferon- stimulated gene modulation depend on the biologic system and may result in the inhibition of viral replication in infected cells, inhibition of cell proliferation, and immunomodulation. Pegylation of the interferon molecule increases its size; the absorption of the larger pegylated molecule is slower, its half-life is longer, and its rate of clearance from the plasma is lower than that of the native interferon. Thus, the pegylated molecule increases the duration of biologic activity. Factors that appear to influence the success of pegylated interferon therapy are HCV genotype, baseline viral load, presence of fibrosis or inflammation shown on the liver biopsy at baseline, and the patient’s body weight or body surface area. Patients infected with HCV genotype 1 tend to have a lower response rate, require longer courses of therapy, and respond better when treated with a pegylated interferon plus ribavirin. Patients infected with HCV genotypes 2 or 3 have comparable responses when treated with interferon plus ribavirin or pegylated interferon plus ribavirin and can be treated with a lower dose of ribavirin and a shorter course of therapy (24 weeks vs 48 weeks for patients with genotype 1). Studies directly comparing peginterferon alfa-2a and peginterferon alfa-2b have not been performed. [Rev Gastroenterol Disord. 2003;3(2):93–109]
Best of AASLD Highlights from the 53rd Annual Meeting of the American Association for the Study of Liver Diseases