PEMANFAATAN INHIBITOR POMPA PROTON

PADA ANAK DENGAN KASUS GERD

1
Dyaricha Amanda C, 1Evida Wati Samosir, 1M.Ahyar Saputra,
1
Meila Sumita, 1Seny Stamrotul Fuaadiyyah I, 1Sirli Safitri M
Program Study Profesi Apoteker
Universitas 17Agustus 1945
Jakarta

ABSTRACT

Gastroesophageal reflux disease (GERD) defined as reflux dysfunction occurring between gastric to the
esophagus. It is signed by the weakening of pressure or function of the Lower Esophageal Spincter (LES).
Almost 18% of babies suffering from GERD were caused by the weakening of LES. The PPI drugs have been
used frequently for adult but not yet clear its safety for children usage. This paper aimed to identify the
considerations using PPI for children with GERD symptom. Several literatures related with the use of PPI for
children with GERD have been searched and collected. This review concluded that the efficacy data of PPI has
been widely found. However it is critical to consider the benefit and harm emerge if it is going to be used in
Indonesia. Children aged one year up can use PPI for GERD cases but those less than one year are suggested to
use procinetic and H2-receptor antagonist drugs.
Keywords :Proton-Pump Inhibitors usage,Gastroesophageal Reflux Disease, children

ABSTRAK
Gastroesophageal reflux disease (GERD) adalah kelainan reflux yang terjadi antara lambung dengan esofagus
yang berhubungan dengan melemahnya tekanan atau fungsi dariLower Esophageal Spincter (LES). Hampir 18%
populasi bayi menderitaGERDdan kebanyakan disebabkan karena lemahnya LES. Obat golongan PPI
merupakan obat yang sering digunakan pada kasus GERD pada orang dewasa namun belum jelas
penggunaannya pada anak. Artikel ini bertujuan untuk mengidentifikasi hal-hal yang perlu dipertimbangkan
dalam menggunakanPPIuntuk terapiGERDpada anak. Literatur yang berkaitan dengan penelitian penggunaan
PPI pada anak dengan kasus GERD dicari dan dikumpulkan.. Kesimpulan yang dapat diambil dari review ini
adalah data efektifitas obat golongan PPI sudah banyak ditemukan, namun perlu dipertimbangkan manfaat dan
kerugian yang akan ditimbulkan apabila obat tersebut ingin digunakan di Indonesia. Anak dengan usia diatas 1
tahun dapat menggunakan obat golonganPPI pada kasusGERDnamun anak dengan usia dibawah 1 tahun obat
golongan prokinetik dan obat golongan antagonis H2-reseptor merupakan obat pilihan.
Kata kunci :penggunaan,Proton-Pump Inhibitors,Gastroesophageal Reflux Disease, anak.

PRELIMINARY
Gastroesophageal Reflux Disease (GERD)
is a pathological condition as a result of
reversing (reflux) the contents of the
stomach into the esophagus exceeding the
normal number and causing various
complaints (Vakil et all, 2006). The
prevalence of GERD around the world in
adults averages 11% to 38.8% and is
different in each country (Guarner, 2008).
The incidence of GERD has increased in
Asia; in Malaysia the prevalence of GERD
2.7% (1991-1992) became 38.8% (2004),
in Singapore the prevalence of GERD
reached 10.5%, whereas in Indonesia data
collection on GERD prevalence had not
been conducted (Jung et all, 2011).
Gastroesophageal Reflux Disease (GERD)
is usually also characterized by heartburn
and regurgitation. Regurgitation is the
result of rising (reflux) stomach acid to
feel bitter on the tongue.
Proton pump inhibitors (PPI) are a class of
drugs that are widely prescribed, which are
used in the treatment of gastrointestinal
(GI) disorders. They act by inhibiting H + /
K + -adenosine triphosphatase (ATPase)
or proton pump, which is located in the
very acidic lumen of the parietal cell
(Blume et al., 2006). This highly acidic
environment allows the conversion of PPIs
to an active protonation state which then
inhibits proton pump activity, causing an
increase in gastric pH.
Among the PPI drugs themselves there are
advantages with one another, for example
esomeprazole at a dose of 40 mg a day is
more effective in controlling stomach acid
compared to omeprazole, lansoprazole,
pantoprazole and rabeprazole in patients
with GERD cases (Mineret al., 2003). In
the case of erosive esophagitis
lansoprazole with a dose of 30 mg does not
have a difference in effectiveness with
omeprazole in a meta-analysis (Sharma
and Leontiadis, 2001)
PPI group drug use is often used even
though the Food Drug and Administration
(FDA) has not allowed its use in children
(Williams and Schade, 2008). Clinical
trials show that the use of PPIs in infants is
not effective. Greater safety data and
clinical randomized trials, placebo-
controlled trials are needed to ensure the
use of PPI-class drugs in children (Tolia,
2010). Child patients who have had GERD
are also at risk of experiencing the disease
again after growing up (Park and Chang,
2012).
Based on age, the development of children
from infants to adults can be classified into
3 stages. The first stage is infants aged
between 1 and 12 months, the second stage
is toddlers and children aged between 1
and 10 years and the third stage is adult
children aged between 11 and 18 years
(Bharwani, 2011). Promolytic substances
and antagonists H2 receptors are often
used to treat GERD cases in children and
infants. The drug dose of the H2-resseptor
antagonist can be seen in the following
table (Lorenzoet al., 2006; Lightdale and
Gremse, 2013).
PPI class drugs are drugs that are often
used in cases of gastric wounds, GERD
and infection by helicobacter pylori both in
adults and in children over the age of 1
year. All golpPPI drugs do not have the
right dosage for children under 1 year
except omeprazole for cases of esophagitis
erosion (Ward and Kearns, 2013). In the
case of using PPI, data with sufficient
evidence is a strong reason to be used as
an excuse
use drugs in children without further
clinical studies (Tafuriet al., 2009). The
strategy for treating GERD cases in
children is based on studies of treatment in
adults. This strategy is based on the small
number of controls and randomization in
pediatric patients (Guimaraes et al., 2006).
Therefore this article aims to identify
things that need to be considered in using
PPI to treat GERD cases in children.
METHODOLOGY
Research on the Use of PPIs in Children
with GERD Cases
Several studies that support and support
the use of PPI in children have been
carried out in various countries. Research
that supports the use of PPIs in children
will be presented below. One study states
that lansoprazole doses for cases of reflux
esophagitis that are safe and effective for
children are 30 mg / m2 or 1.4 mg / kg
(Faureet al., 2001). Research in America
states that pantoprazole has not been
approved for use by those under the age of
18, whereas in Europe pantoprozol may be
used by those over 12 years of age (Tolia,
2008). Omeprazole given at a dose of 0.3-
3.5 mg / kg once a day given for 12 weeks
is effective for treating esophagitis in
children (Monzani and Oderda, 2010).
Research on the use of esomeprazole given
at a dose of 0.2-1.0 mg / kg for 8 weeks
has been done in children aged 1-11 years.
The results show that esomeprazole is
effective in dealing with erosive cases of
esophagitis in a population of children
with GERD (Toliaet al., 2010). Other
research data states that PPIs can be used
by those over the age of 11 (Hassallet al.,
2007). Research in India states that based
on empirical therapy carried out in India,
PPI can be used in adult children to deal
with reflux symptoms (Poddar, 2013).
Other studies suggest that pediatric
patients suffering from reflux esophagitis
without other dangerous diseases can be
cured with acid suppression drugs (Park
and Chang, 2012)
The effectiveness of the PPI class of drugs
in treating gastric wounds, GERD and
infection with Felicobacter pylori has been
proven for children
over 1 year old. For pediatric patients
under 1 year the effectiveness of the PPI
class has not been proven except
omeprazole in erosive cases of esophagitis.
Long-term treatment in pediatric patients
with GERD cases does not cause cancer
and significant abnormalities (Ward and
Kearns, 2013). The above statement is
reinforced by studies involving children
aged 3 to 12 months with cases of GERD
or esophagitis given omeprazole for 4
weeks. This study states that omeprazole
significantly reduced exposure to
esophageal acid compared with placebo
(Moore et al., 2003). Other data suggest
that esomeprazole has better
pharmacological properties than
omeprazole. Esomeprazole also has the
same ability as omeprazole to treat GERD
cases in children (Guimaraeset al., 2010).
Research that does not support the use of
PPI drugs in children will be described
below. Systematic reviews to see the
effectiveness and safety of PPI have been
carried out and the results show that PPI is
not effective in reducing GERD symptoms
in infants. Although PPI is well tolerated
in children, PPI trials using placebo and
control in children are still rare (Van der
Polet al., 2011). Systematic reviews of the
use of acid suppression drugs to treat
GERD in infants and children have been
carried out. The results show that the use
of H2-receptor and PPI antagonists is
closely related to the incidence of
gastrointestinal infections, pneumonia,
sepsis and necrosis of enterocolitis in
infants and children. Based on the results
of this analysis, it is necessary to pay
attention to the use of acid suppression
drugs (H2-receptor antagonists and PPI) in
the case of GERD in infants and children
(Chung and Yardley, 2013).
A systematic review of the effectiveness of
PPIs for GERD cases in children has been
carried out in 12 studies involving children
aged 0 to 17 years. The results stated that
for infants PPI use was more effective in 1
study, ineffective in 2 studies, and equally
effective in 2 studies compared with
placebo in reducing GERD symptoms. The
results of the analysis state that PPI is not
effective in reducing PPI symptoms.
Experiments using control and placebo are
rarely done and data that supports security
the use of PPI is rarely done (Lightdale
and Gremse, 2013). Another study that
assessed the effect of PPI with a unit of
week time had been carried out on
pediatric patients with GERD. The results
show that PPI does not affect the total
incidence of reflux, the amount of fluid
released but can reduce the acidity of the
liquid. the results of this study also state
that esophagitis can be cured using PPI for
2 months (Turket al., 2013).
DISCUSSION
Research data on the effectiveness of PPI-
class drug use for GERD cases in children
has been widely published from various
countries. Some of the data supports and
some of the data is less supportive of the
use of PPI drugs for GERD cases in
children. However, from litaratur
recommending dosage for GERD cases in
children, it can be said that the
golonganPPI drug can be used for children
over the age of 1 year. Although several
systematic reviews and meta-analyzes
have been carried out to assess the use of
PPIs in child GERD cases, the application
in Indonesia still needs to be considered.
These considerations need to be supported
by comprehensive and structured data
about experiences or research involving
children in Indonesia. This data is very
important considering the condition of
Indonesian children is different from the
condition of children in other countries,
both in terms of genetic traits, food intake,
disease exposure and the surrounding
environment. With the complete data, it
will be easy for pediatricians or other
doctors who treat children to recommend
the use of PPI-class drugs in children with
GERD cases.
At present, careful consideration is needed
to use PPI class drugs in children. Taking
into account the benefits and losses that
will be experienced is the right step in
treating GERD in children. For children 1
year of age or older, supporting data is
sufficient, but it is important to consider
the use of other drugs to treat GERD cases
in children such as H2-receptor antagonists
and prokinetic drugs. The latest data
recommends the use of a combination of
these two classes of drugs for infants and
children. Whereas children are aged ess
than 1 year of use of H2-receptor
antagonists is permissible as ranitidine
starts at the age of 1 month.
This is related to the function of
gastrointestinal motility in imperfect
infants so that drugs are needed that
increase the gastrointestinal motility
function. The use of prokinetic drugs will
increase gastrointestinal motility. By
increasing gastrointestinal motility, the
esophageal movement process will
increase and the gastric emptying process
will be faster. This will push the stomach
contents faster into the intestine, so that the
movement of reflux digestion can be
avoided.
This literature study is incomplete without
clinical experience, special research on the
use of PPI in children and the opinions of
experts, especially pediatricians, pediatric
gastrohepatology specialists in Indonesia.
So it is necessary to coordinate steps that
result in a written agreement that
recommends the use of PPI drugs in cases
of GERD in both infants and children.
This agreement is important so that the
doctors or nurses do not hesitate in doing
therapy using PPI class drugs in GERD
cases
child. This agreement will be better if it is
made in the form of GERD treatment
guidelines in infants, toddlers and children.
This guide can be disseminated to all
hospitals or health centers in Indonesia.
With the existence of a guidebook it is
hoped that there will be no hesitation in
using PPI-class drugs to record cases of
GERD in infants, toddlers and children
CONCLUSION
From some of the literature and the results
of the discussion carried out, conclusions
can be drawn including: 1. Data on the
effectiveness of the PPI class of drugs
have been found but need to be considered
the benefits and losses that will be caused.
So that a guideline for treating GERD is
needed by using PPI that is in accordance
with the conditions of children in
Indonesia. 2. PPI drugs can be used in
cases of GERD for children over the age of
1 year while children under the age of 1
year can use prokinetic drugs such as
metoclopramide and H2 antagonist drug
receptors such as ranitidine
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