JOAQUIM PRADO PINTO DE MORAES FILHO
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Departamento de Gastroenterologia, Faculdade de Medicina - Docente
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- Refractory gastroesophageal reflux disease(2012) MORAES-FILHO, Joaquim Prado P.CONTEXT: Gastroesophageal reflux disease (GERD) is a condition which develops when the reflux of stomach contents causes troublesome symptoms and/or complications. Its pathophysiology, diagnosis and treatment have frequently been analyzed but it is interesting to review some aspects of the GERD refractory patients to the proton pump inhibitors treatment. The treatment encompasses behavioral measures and pharmacological therapy. The majority of the patients respond well to proton pump inhibitors treatment but 20%-42% of them may not do so well. Patients who are unresponsible to 4-8 weeks' treatment with proton pump inhibitors (omeprazole, pantoprazole, rabeprazole, lansoprazole, esomeprazole, pantoprazole-Mg) might have so-called refractory GERD. RESULTS: In some cases the patients are not real refractory because either they do not have GERD or the disease was not correctly treated, but the term refractory is still employed. Although debatable, the Brazilian GERD Consensus based upon evidences recommends as first step in the diagnosis, the upper digestive endoscopy to exclude the diagnosis of peptic ulcer and cancer and in some cases identify the presence of esophageal mucosa erosions. CONCLUSIONS: The main causes of the so-called refractory GERD are: (1) functional heartburn; (2) low levels of adherence to proton pump inhibitors treatment; (3) inadequate proton pump inhibitors dosage; (4) wrong diagnosis; (5) co-morbidities and pill-induced esophagitis; (6) genotypic differences; (7) nonacid gastroesophageal reflux; (8) autoimmune skin diseases; (9) eosinophilic esophagitis.
- Vonoprazan in the management of gastric/peptic ulcers: a systematic review of safety data(2022) MORAES-FILHO, Joaquim Prado P.; DOMINGUES, Gerson; GUEDES, Juliana Leite Soares; ZATERKA, SchliomaIntroduction: Although potassium-competitive acid blockers (P-CABs) prompted safety concerns when first developed, they ultimately proved to have a favourable safety profile.Aim: To assess the safety of vonoprazan in the management of gastroesophageal reflux disease (GERD), peptic ulcers, or gastroduodenal mucosal lesions induced by chronic use of aspirin or non-steroidal anti-inflammatory drugs (NSAIDs).Material and methods: From March to June 2021, a literature search was conducted using Medline via PubMed, Cochrane library, Lilacs, SciELO, and Centre for Reviews and Dissemination (CRD) electronic databases. After applying the eligibility criteria, 10 studies were included in this review. Of these 10 articles, vonoprazan was used as initial therapy in 6 and as maintenance therapy in 4. Adverse event rates were similar for vonoprazan and proton-pump inhibitors (PPIs). Conclusions: Our findings suggest that vonoprazan is a safe option for the management of erosive oesophagitis, gastric/ peptic ulcers, or peptic ulcers induced by chronic use of aspirin or NSAIDs.
- Commentary: daily pantoprazole vs. esomeprazole for GERD - authors' reply(2014) MORAES-FILHO, J. P.; PEDROSO, M.; QUIGLEY, E. M. M.
- Randomised clinical trial: daily pantoprazole magnesium 40 mg vs. esomeprazole 40 mg for gastro-oesophageal reflux disease, assessed by endoscopy and symptoms(2014) MORAES-FILHO, J. P.; PEDROSO, M.; QUIGLEY, E. M. M.BackgroundPantoprazole magnesium (pantoprazole-Mg) may display extended inhibition of the proton pump with the potential for improved clinical efficacy in gastro-oesophageal reflux disease (GERD). AimTo compare the efficacy of pantoprazole-Mg and esomeprazole in GERD. MethodsGastro-oesophageal reflux disease (Los Angeles grades A-D) patients were randomised to 4weeks of treatment with pantoprazole-Mg (n=290) or esomeprazole (n=288), both 40mg once daily, in this multicentre (14 Brazilian sites in 9 cities), double-blind study, with an additional 4weeks' treatment in nonresponding patients. Severity of oesophagitis (at endoscopy) and GERD-related symptoms (ReQuest-GI) were assessed. The primary end point was the proportion of patients in complete remission (ReQuest-GI score <1.73 plus endoscopic healing) at week 4. ResultsComplete remission occurred in 61% of patients in each treatment group at 4weeks (primary endpoint) and in 81% and 79% of patients in the pantoprazole-Mg and esomeprazole groups at 8weeks, with no significant differences. Mucosal healing rates were high and not significantly different. At 8weeks, symptom relief with pantoprazole-Mg was significantly greater than that with esomeprazole (91.6% vs. 86.0%, P=0.0370) because of continued improvement in symptoms with pantoprazole-Mg from week 4 to week 8 (P=0.0206). ConclusionsPantoprazole-Mg 40mg was at least as effective as esomeprazole 40mg for complete remission and the mucosal healing rate was high. Symptom relief with pantoprazole-Mg continued to improve from 4 to 8weeks and was greater than that with esomeprazole at week 8, suggesting an extended period of treatment effect (ClinicalTrials.gov identifier: NCT01132638).
- GASTROESOPHAGEAL REFLUX DISEASE: A PRACTICAL APPROACH(2021) DOMINGUES, Gerson; MORAES-FILHO, Joaquim Prado P deABSTRACT Gastroesophageal reflux disease (GERD) presents typical manifestations such as heartburn and/or regurgitation as well as atypical manifestations such as throat symptoms, laryngitis, hoarseness, chronic cough, asthma, and sleep alterations. There are two phenotypes of the disease: erosive GERD, when erosions are identified by upper digestive endoscopy, and non-erosive GERD, when the esophageal mucosa presents a normal endoscopic aspect. Relevant clinical findings are usually absent in the physical examination, but it should be highlighted that obesity is an important aggravating factor of reflux. The treatment is established based on clinical findings and, according to the clinical situation, on complementary exams such as upper digestive endoscopy. In dubious cases where a precise diagnosis is required, the indicated test is esophageal pHmetry or impedance-pHmetry. Clinical treatment is divided into behavioral/dietary measures and pharmacological measures. Most patients benefit from clinical treatment, but surgical treatment may be indicated in the presence of a larger hiatal hernia and complications of the disease.
- Potassium-competitive acid blockers, a new therapeutic class, and their role in acid-related diseases: a narrative review(2023) DOMINGUES, Gerson; CHINZON, Decio; MORAES-FILHO, Joaquim Prado P.; SENRA, Juliana Tosta; PERROTTI, Marcos; ZATERKA, SchliomaIntroduction: A new therapeutic class, potassium-competitive acid blockers (P-CABs), has emerged in Brazil to promote a superior antisecretory effect addressing the unmet needs related to acid-related disease management. Vonoprazan fumarate showed a good safety profile and was approved by the Brazilian regulatory agency - ANVISA.Aim: This narrative review was conducted to review the general concepts regarding P-CABs, focussing on vonoprazan fu-marate.Material and methods: A literature search was conducted through April-May 2021 using official databases with a combi-nation of MeSH controlled vocabulary and text words. The authors selected articles that described pivotal and novel insights about P-CABs and vonoprazan fumarate.Results: Vonoprazan is a drug of the P-CABs class newly approved for the management of acid-related diseases in Brazil. P-CABs achieve rapid, potent, and prolonged acid suppression (including night-time) and promise to address some unmet clinical needs in GERD. Furthermore, considering the difficulties encountered in attaining effective symptomatic control - particularly at night - using currently available PPIs, this new drug class is promising.Conclusions: This review brings important information about vonoprazan, a new therapeutic option in Brazil, which may be considered as a valuable tool for managing acid-related diseases.
- Low levels of adherence with proton pump inhibitor therapy contribute to therapeutic failure in gastroesophageal reflux disease(2012) DAL-PAZ, K.; MORAES-FILHO, J. P.; NAVARRO-RODRIGUEZ, T.; EISIG, J. N.; BARBUTI, R.; QUIGLEY, E. M. M.To assess adherence to proton pump inhibitor (PPI) treatment and associated variables in patients with gastroesophageal reflux disease (GERD). Cross-sectional and prospective comprising 240 consecutive adult patients, diagnosed with GERD for whom continuous use of standard or double dose of omeprazole had been prescribed. Patients were ranked as ne-GERD (162: 67.5%) or e-GERD classified according to the Los Angeles classification as A (48:20.0%), B (21:8.6%), C (1:0.5%), D (1:0.5%), and Barrett's esophagus (7:2.9%). The Morisky questionnaire was applied to assess adherence to therapy and a GERD questionnaire to assess symptoms and their impact. Adherence was correlated with demographics, cotherapies, comorbidities, treatment duration, symptoms scores, endoscopic findings, and patient awareness of their disease. 126 patients (52.5%) exhibited high level of adherence and 114 (47.5%) low level. Youngers (P= 0.002) or married (O.R. 2.41, P= 0.03 vs. widowers) patients had lower levels of adherence; symptomatic patients exhibited lower adherence (P= 0.02). All other variables studied had no influence on adherence. Patients with GERD attending a tertiary referral hospital in Sao Paulo exhibited a high rate of low adherence to the prescribed PPI therapy that may play a role in the therapy failure. Age <60 years, marital status and being symptomatic were risk factors for low adherence.
- NORMAL VALUES OF ESOPHAGEAL HIGH-RESOLUTION MANOMETRY: A BRAZILIAN MULTICENTER STUDY(2020) DOMINGUES, Gerson Ricardo; MICHELSOHN, Nelson Henrique; VIEBIG, Ricardo Guilherme; CHINZON, Décio; NASI, Ary; ANDRADE, Carla Granja; LEMME, Eponina Maria; ABRAHÃO JUNIOR, Luiz João; BRAVIM, Mauricio Gustavo; NOBRE-E-SOUZA, Miguel Ângelo; CARVALHO, Nayara Salgado; CARVALHO, Paulo J P C; RODRIGUES, Tomás Navarro; MORAES FILHO, Joaquim Prado PABSTRACT BACKGROUND: The high-resolution manometry has been a significant advance in esophageal diagnostics. There are different types of catheter and systems devices to capture esophageal pressures that generate variable data related to Chicago Classification (CC) and consequently influence normal values results. There are not normative data for the 24-channel water-perfused high-resolution manometry system most used in Brazil with healthy volunteers in supine posture. OBJECTIVE: To determine manometric esophageal normative values for a 24-channel water-perfused high-resolution manometry catheter in supine posture using healthy volunteers according to CC 3.0 parameters. METHODS: A total of 92 volunteers with no gastrointestinal symptoms or medications affecting GI motility underwent esophageal high-resolution manometry by standard protocol. Age, gender and manometry parameters analyzed using Alacer software were collected. The median, range, and 5th and 95th percentiles (where applicable) were obtained for all high-resolution manometry metrics. Normal value percentiles were defined as 95th integrated relaxation pressure, 5th-100th distal contractile integral, and 5th distal latency. RESULTS: The mean age was 40.5±13.2 years. Our normative metrics were integrated relaxation pressure <16 mmHg and distal contractile integral (708-4111 mmHg.cm.s) distal latency was <6 s and peristaltic break size (>4 cm). For EGJ-CI the range 5th-95th was 21.7-86.9 mmHg.cm.s. CONCLUSION: This is the first report of normative data for the 24-channel water-perfused system in supine posture. It revealed higher integrated relaxation pressure and distal latency duration which suggest the need to change CC 3.0 cutoffs for this system. It is observed that there is a tendency that DCI >7000 mmHg.cm.s may represent the lower limit of hypercontractility, and when <700 mmHg.cm.s (<5% percentile) interpreted as ineffective esophageal motility or failcontraction. Also compared to Chicago 3.0, higher integrated relaxation pressure and duration of distal latency were found. We emphasize that these data must be confirmed by future studies.
- THE INTESTINAL MICROBIOTA AND THE ROLE OF PROBIOTICS IN IRRITABLE BOWEL SYNDROME: a review(2015) MORAES-FILHO, Joaquim Prado; QUIGLEY, Eamonn M MIrritable bowel syndrome is a common, chronic relapsing gastrointestinal disorder that affects 7%-22% of the population worldwide. According to Rome III Criteria, the disorder is defined by the coexistence of abdominal discomfort or pain associated with an alteration in bowel habits. Its pathophysiology is not completely understood but, in addition to some important abnormalities, the disturbed intestinal microbiota has also been described supported by several strands of evidence. The treatment of irritable bowel syndrome is based upon several therapeutic approaches but few have been successful or without adverse events and more recently the gut microbiota and the use of probiotics have emerged as a factor to be considered. Probiotics are live micro-organisms which when consumed in adequate amounts confer a health benefit to the host, such as Lactic bacteria among others. An important scientific rationale has emerged for the use of probiotics in irritable bowel syndrome, although the data regarding different species are still limited. Not all probiotics are beneficial: it is important to select the specific strain which should be supported by good evidence base. The mechanisms of action of probiotics are described and the main strains are quoted.
- Esophageal motility patterns are altered in older adult patients(2020) KUNEN, L. C. B.; FONTES, L. H. S.; MORAES-FILHO, J. P.; ASSIRATI, F. S.; NAVARRO-RODRIGUEZ, T.Introduction and aims: Since the 1960s, several studies have shown the effect of aging on esophageal motility, with inconsistent results. The aim of the present study was to evaluate the manometric results in older adult patients (>= 60 years of age) with an esophageal disorder and compare them with adults under 60 years of age. Materials and methods: A cross-sectional, retrospective study was conducted that included a sample of 1,175 patients (936 older adults and 239 non-older adults). The patients were evaluated and compared with respect to (i) sex, (ii) main complaint for which esophageal manometry was indicated, (iii) comorbidities, (iv) current medications, (v) smoking, and (vi) manometry results. Results: Patient age ranged from 19 to 92 years (women made up 76.5% of the older adults and 72.8% of the non-older adults). Normal lower esophageal sphincter relaxation and normal peristalsis were more frequent in the non-older patient group (91.1% vs. 84.8% and 87.4% vs. 76%, respectively). The manometry results for the non-older adults vs. the older adults, respectively, were: achalasia (2.9% vs. 5.9%); hypercontractile disorder (9.2% vs. 10.4%); hypocontractile disorder (38.5% vs. 47.6%); and normal values (49.4% vs. 36.1%). After excluding the variables that could change esophageal motility, the results revealed significant differences between the two study groups. Conclusions: Esophageal manometry demonstrated statistically significant differences between the older adult and non-older adult study population evaluated. (C) 2019 Asociacion Mexicana de Gastroenterologia.