Cost analysis of long-term treatment of patients with symptomatic gastroesophageal reflux disease (GERD) with esomeprazole on-demand treatment or esomeprazole continuous treatment: an open, randomized, multicenter study in Switzerland

OBJECTIVES

To assess the difference in direct medical costs between on-demand (OD) treatment with esomeprazole (E) 20 mg and continuous (C) treatment with E 20 mg q.d. from a clinical practice view in patients with gastroesophageal reflux disease (GERD) symptoms.

METHODS

This open, randomized study (ONE: on-demand Nexium evaluation) compared two long-term management options with E 20 mg in endoscopically uninvestigated patients seeking primary care for GERD symptoms who demonstrated complete relief of symptoms after an initial treatment of 4 weeks with E 40 mg. Data on consumed quantities of all cost items were collected in the study, while data on prices during the time of study were collected separately. The analysis was done from a societal perspective.

RESULTS

Forty-nine percent (484 of 991) of patients randomized to the OD regimen and 46% (420 of 913) of the patients in the C group had at least one contact with the investigator that would have occurred nonprotocol-driven. The difference of the adjusted mean direct medical costs between the treatment groups was CHF 88.72 (95% confidence interval: CHF 41.34-153.95) in favor of the OD treatment strategy (Wilcoxon rank-sum test: P < 0.0001). Adjusted direct nonmedical costs and productivity loss were similar in both groups.

CONCLUSIONS

The adjusted direct medical costs of a 6-month OD treatment with esomeprazole 20 mg in uninvestigated patients with symptoms of GERD were significantly lower compared with a continuous treatment with E 20 mg once a day. The OD therapy represents a cost-saving alternative to the continuous treatment strategy with E.

Seven-day PPI-triple therapy with levofloxacin is very effective for Helicobacter pylori eradication

BACKGROUND

Helicobacter pylori infection causes lifelong gastritis and is associated with the development of peptic ulcer disease, MALT lymphoma and gastric cancer. Many patients benefit from H. pylori eradication therapy. PPI-triple therapy is recommended as initial therapy. Quadruple therapy, with a PPI, bismuth, and two antibiotics, used to be recommended as second-line therapy, but can no longer be prescribed because bismuth is no longer available. Therefore, there is an urgent need for new effective rescue therapies. Levofloxacin-based therapies were suggested as an alternative to quadruple therapy. The aim of this study is to examine the efficacy and tolerability of such a one-week therapy with levofloxacin and esomeprazole combined with either amoxicillin or clarithromycin in a Dutch population.

METHODS

Between February 2005 and November 2006, 123 consecutive H. pylori positive patients were enrolled in this study. The first 59 patients were treated with esomeprazole, amoxicillin and levofloxacin (group I). The next 64 patients were treated with esomeprazole, clarithromycin, and levofloxacin (group II ). Both therapies were compared for efficacy and tolerability.

RESULTS

In group I the overall (ITT) cure rate was 96% and in group II it was 93%. Minor side effects occurred in 29% of patients in group I and in 41% of patients in group II. Major side effects that warranted discontinuation of therapy occurred in two patients in group II.

CONCLUSION

Seven-day triple therapy with esomeprazole, levofloxacin and either amoxicillin or clarithromycin for seven days is very effective and safe for H. pylori eradication. The combination with amoxicillin seems to be better tolerated than the combination with clarithromycin.

Peptic ulcer bleeding following therapeutic endoscopy: a new indication for intravenous esomeprazole

Intravenous (IV) administration of the esomeprazole is a faster way to achieve gastric acid suppression than oral administration of the same agent. Peak suppression following IV administration occurs within hours compared with several days following oral administration. Thus, the IV administration route offers a faster onset of gastric suppression, achievement of intragastric pH closer to target levels, and better bioavailability. Treatment of peptic ulcer bleeding is the newest indication for the IV formulation of esomeprazole. The drug is effective in preventing rebleeds following endoscopic treatment when administered within 24 hours of the procedure as an 80-mg bolus followed by an IV infusion for 72 hours. What remains to be seen is whether oral therapy can be substituted for all, or part, of the 72-hour IV infusion and whether the patient can be discharged from the hospital sooner with similar outcomes.

The effectiveness of esomeprazole 40 mg in patients with persistent symptoms of gastro-oesophageal reflux disease following treatment with a full dose proton pump inhibitor

BACKGROUND

Some patients with gastro-oesophageal reflux disease (GORD) remain symptomatic despite proton pump inhibitor (PPI) treatment. There is a need to determine the most appropriate management of these patients.

AIMS

To assess the effectiveness of esomeprazole 40 mg in GORD symptoms persisting in patients receiving a full daily dose PPI.

METHODS

In this multi-centre open label study patients who had received full daily dose PPI for 8 weeks, but were still experiencing persistent GORD symptoms, were treated with esomeprazole 40 mg for 8 weeks (n = 99). The primary outcome variable was the change in the frequency of heartburn. Patient-reported outcomes were also assessed using the Reflux Disease Questionnaire (RDQ) and the GORD Impact Scale (GIS).

RESULTS

The mean frequency of heartburn was reduced by 78% from 4.4 days a week to 1 day a week at the end of the 8-week treatment period (p < 0.0001). Other GORD symptoms were also significantly reduced following of treatment with esomeprazole (all p < 0.0001). All RDQ dimensions and the level of symptom control as measured by the GIS also showed significant improvement at 8 weeks.

CONCLUSIONS

In patients with persistent GORD symptoms despite full dose daily PPI therapy, esomeprazole 40 mg significantly improved the frequency and severity of all GORD symptoms.

Effect of acid suppression on gastric myoelectrical activity in GERD

BACKGROUND/AIMS

The study aimed to investigate whether acid suppression influences gastric myoelectrical activity in patients with reflux disease.

METHODOLOGY

Twenty-eight patients with erosive esophagitis underwent electrogastrography. All patients were studied before and after esomeprazole. Subjects were divided into mild or moderate esophagitis in order to determine any variation in response related to esophagitis severity.

RESULTS

The reflux symptom improved from 4.2 at baseline to 1.0 at week 8 (P < 0.001). A significant increase in postprandial gastric 3 cycle per minute (normal) activity was observed at week 8 (P < 0.05). There was also significantly increased postprandial gastric 3 cycle per minute (normal) activity in moderate esophagitis (P < 0.05).

CONCLUSIONS

The effect of acid suppression on gastric myoelectrical activity is subtle with an enhancement in normal gastric myoelectrical activity. The myoelectrical response to acid suppression appears to be associated with esophagitis severity.

High-dose versus low-dose esomeprazole-based triple therapy for Helicobacter pylori infection

BACKGROUND

This prospective, randomized, controlled study was conducted to compare the efficacies of high-dose and low-dose esomeprazole-based triple therapies for Helicobacter pylori eradication in Taiwan.

MATERIALS AND METHODS

From January 2004 to June 2006, 240 H. pylori-infected patients were randomly assigned to undergo high-dose (40 mg b.d.) or low-dose (40 mg o.d.) esomeprazole combined with clarithromycin (500 mg b.d.) and amoxicillin (1 g b.d.) for one week. Follow-up endoscopy was performed at eight weeks after the end of treatment to evaluate the response to therapy.

RESULTS

Intention-to-treat analysis demonstrated no differences between eradication rates of high-dose and low-dose groups (92% vs. 90%, respectively, P > 0.05). Per-protocol analysis yielded comparable results (95% vs. 93%). Both groups exhibited similar frequencies of adverse events (13% vs. 11%) and drug compliance (96% vs. 93%). Multivariate analysis indicated that only good compliance (odds ratio: 10.3, 95% CI, 3.0-35.7) was an independent predictor of treatment success.

CONCLUSIONS

This work demonstrates that low-dose esomeprazole-based triple therapy yields a similar eradication rate as high-dose esomeprazole-based therapy in Taiwan. Since the cost of the low-dose regime is lower than that of the high-dose regime, low-dose esomeprazole-based triple therapy can reasonably be recommended for the first-line eradication of H. pylori for Taiwanese and probably most Asians.

Randomized-controlled trial of esomeprazole in functional dyspepsia patients with epigastric pain or burning: does a 1-week trial of acid suppression predict symptom response?

BACKGROUND

Early identification of true responders to acid suppression in functional dyspepsia patients with symptoms of epigastric pain or burning may enable clinicians to optimally tailor treatment.

AIM

To evaluate whether a 1-w acid suppression trial is useful for identifying true responders in this population.

METHODS

Patients (18-70 years) were randomized to either esomeprazole 40 mg q.d.s., b.d. or placebo for 1w, and then esomeprazole 40 mg q.d.s. or placebo for 7w. Epigastric pain and/or burning were recorded on a 4-point scale (0 = none, 3 = severe). Trial-week response was defined as symptom score sum < or = 1 on last 3d of therapy; response at 8w was symptom score sum < or = 1 over preceding 7d.

RESULTS

1-w response rates were 33% (199 of 597), 29% (188 of 629) and 23% (71 of 315) with esomeprazole q.d.s., esomeprazole b.d. and placebo, respectively (P = 0.002 for esomeprazole groups vs. placebo). At 8w, trial week sensitivity and specificity were 46% and 80%, respectively, for esomeprazole (40 or 80 mg), and 33% and 87%, respectively, for placebo. The positive and negative predictive values for esomeprazole were 60% and 69%.

CONCLUSION

Response to a 1-w acid suppression trial is of limited use for predicting symptom response at 8w in patients with unexplained epigastric pain or burning.

One-week acid suppression trial in uninvestigated dyspepsia patients with epigastric pain or burning to predict response to 8 weeks' treatment with esomeprazole: a randomized, placebo-controlled study

BACKGROUND

While empiric acid-suppressive therapy for uninvestigated dyspepsia patients with symptoms of epigastric pain or burning is standard practice, it is unknown whether an early response to therapy predicts outcome.

AIM

To evaluate whether a 1-w acid suppression trial is effective for predicting 8-w response in such patients.

METHODS

Helicobacter pylori-negative patients (aged 18-50 years) in primary care with uninvestigated epigastric pain or burning were randomized to esomeprazole 40 mg q.d.s. or b.d. for 1w, followed by esomeprazole 40 mg q.d.s. or placebo for 7w. Each day, patients rated the severity of their symptoms.

RESULTS

Based on the last 3d, 1-w response rates were 39% (231 of 588) and 43% (258 of 596) with esomeprazole 40 mg q.d.s. and b.d., respectively. Based on the last 7d, response rates at 4w were 38% (283 of 738) and 25% (93 of 380) for esomeprazole and placebo, respectively, and 47% (339 of 716) and 34% (124 of 368), respectively, at 8w (both P < 0.001 vs. placebo). The sensitivity and specificity of esomeprazole treatment were 58% and 70%, respectively, at 8w.

CONCLUSION

A 1-w acid suppression trial is of limited clinical value for predicting 8-w response in patients with symptoms of epigastric pain or burning. Esomeprazole provides greater symptom control than placebo at 4w and 8w.

Pantoprazole 40 mg is as effective as esomeprazole 40 mg to relieve symptoms of gastroesophageal reflux disease after 4 weeks of treatment and superior regarding the prevention of symptomatic relapse

BACKGROUND/AIM

Little is known about the symptom course during and after treatment of gastroesophageal reflux disease (GERD). Here we address this question in patients with erosive GERD treated with pantoprazole or esomeprazole 40 mg once daily using the validated reflux questionnaire ReQuest.

METHODS

Of 585 patients enrolled, 561 (intention-to-treat; ITT) patients with endoscopically confirmed GERD grades A-D (Los Angeles Classification) were randomized. To assess the GERD symptomatology, the patients completed the ReQuest daily, and analysis was done prior to (7 days), during (28 days), and after treatment (7 days). The mean scores (last 3 treatment days) of the subscale ReQuest-GI (gastrointestinal complaints) were compared between both groups. After the end of treatment, the number of symptom episodes and the rate of relapses were calculated.

RESULTS

Noninferiority of pantoprazole versus esomeprazole during treatment was shown (mean ReQuest-GI score). During the posttreatment period, the proportion of patients experiencing a symptomatic relapse (51 vs. 61%, p = 0.0216, ITT) and the number of symptom episodes (0.56 vs. 0.74, p = 0.0095, ITT) were significantly lower on pantoprazole than on esomeprazole.

CONCLUSIONS

Pantoprazole 40 mg was at least as effective as esomeprazole 40 mg for relieving GERD symptoms. During the posttreatment phase, patients on pantoprazole had a significantly lower risk to relapse and experienced significantly fewer symptom episodes.

Diagnostic value of the Reflux Disease Questionnaire in general practice

OBJECTIVES

This study determined the diagnostic and therapeutic response of the Reflux Disease Questionnaire (RDQ) using the symptom association probability (SAP) as reference. In addition, the RDQ's construct validity and its relationship to quality of life (QOL) were ascertained.

METHODS

Seventy-four patients with GORD symptoms (age 51 years (22-78); male 62%) derived from primary care completed the RDQ, GSRS and QOLRAD before and after a 2 weeks' course of esomeprazole 40 mg daily. The SAP was determined by a 24-hour pH recording before PPI treatment. The diagnostic abilities of the RDQ (total and 4 dimensions scores) were assessed with the area under the curve (AUC) of a receiver operating curve. RDQ scores before and after PPI treatment were compared with Wilcoxon tests. Multiple linear regressions assessed the RDQ's construct validity (GSRS) and relationship to QOL (QOLRAD).

RESULTS

The AUCs were low for all RDQ dimensions (AUC <0.6). In the SAP-positive patients all RDQ dimensions improved (p < 0.0001) while the scores of the SAP negatives did not (heartburn p < 0.01; GORD and total score p < 0.05; regurgitation and dyspepsia n.s.). The RDQ was related to the total and reflux GSRS dimensions while the food and drink QOL dimension was linearly associated with the RDQ.

CONCLUSIONS

The RDQ is a valid and reliable questionnaire with excellent construct validity and a good relationship to QOL. The diagnostic value of the RDQ in primary care is limited, but combination with an additional PPI treatment course might improve the RDQ's ability to discriminate GORD patients according to their SAP outcome.

A new esomeprazole packet (sachet) formulation for suspension: in vitro characteristics and comparative pharmacokinetics versus intact capsules/tablets in healthy volunteers

BACKGROUND

A packet (sachet) formulation of esomeprazole for suspension has been developed for use in patients who have difficulty swallowing.

OBJECTIVES

This article reports the in vitro characteristics of the new esomeprazole formulation, including stability in suspension and suitability for administration orally or via enteral tubes. It also describes the pharmacokinetic profile of the esomeprazole 40-mg packet compared with that of existing solid dosage forms (capsules and tablets) in a clinical bioequivalence study.

METHODS

The stability in suspension of the packet formulation was assessed after reconstitution at various strengths (2.5, 10, and 40 mg) and a different pH (3.4-5.0) in strength-appropriate volumes of water held at temperatures ranging from 5 degrees C to 37 degrees C for up to 60 minutes. Suitability for oral administration was examined in terms of reconstitution time and the actual dose delivered after simulated oral administration, as well as in terms of the actual dose delivered by enteral tubes ranging in diameter from 6 to 20 Fr. Chemical stability and suspension characteristics were also analyzed using alternative reconstitution vehicles (applesauce, apple juice, and orange juice). The comparative pharmacokinetics of the packet, capsule, and tablet formulations of esomeprazole were evaluated in a randomized, open-label, 3-way crossover study in healthy volunteers, who received single 40-mg doses of each formulation. Bioequivalence was assumed if the 90% CIs for the ratios of the geometric mean AUC and CmaX were between 0.80 and 1.25. Reversephase liquid chromatography with ultraviolet detection was used to assess the esomeprazole content and/or degradation products of esomeprazole in the tests for in-suspension stability, dose delivery, and acid resistance. Normal-phase liquid chromatography was used to assess the esomeprazole content of the plasma samples in the bioequivalence study.

RESULTS

At the pH and temperature ranges investigated, the packet formulation was stable for up to 60 minutes after reconstitution. Chemical degradation was low (<0.1%) for all reconstitution vehicles investigated. Reconstitution time was 2 minutes with water and 9 to 10 minutes with apple or orange juice. Dose delivery was >/=98% after simulated oral administration and was generally >/=96% after administration via enteral tubes. Ninety-six healthy volunteers (56 women, 40 men; mean age, 24.9 years; mean weight, 68.9 kg) participated in the randomized, crossover, comparative pharmacokinetic study of the packet and capsule/tablet formulations. The estimated ratios of the geometric mean AUC and C(max) for the packet:capsule and packet: tablet formulations were 0.98 (90% CI, 0.93-1.03) and 0.99 (90% CI, 0.94-1.04), respectively.

CONCLUSIONS

In these analyses, the packet (sachet) formulation of esomeprazole was chemically stable in suspension and when administered orally and via enteral tubes. The formulation had a short reconstitution time, remaining fully dispersed in water for at least 30 minutes, and was dispersed in applesauce, apple juice, or orange juice without compromising its stability or dispersion characteristics. The packet formulation met the regulatory definition for bioequivalence to the tablet and capsule formulations.

Pantoprazole 40 mg is as effective as esomeprazole 40 mg to relieve symptoms of gastroesophageal reflux disease after 4 weeks of treatment and superior regarding the prevention of symptomatic relapse

BACKGROUND/AIM

Little is known about the symptom course during and after treatment of gastroesophageal reflux disease (GERD). Here we address this question in patients with erosive GERD treated with pantoprazole or esomeprazole 40 mg once daily using the validated reflux questionnaire ReQuest.

METHODS

Of 585 patients enrolled, 561 (intention-to-treat; ITT) patients with endoscopically confirmed GERD grades A-D (Los Angeles Classification) were randomized. To assess the GERD symptomatology, the patients completed the ReQuest daily, and analysis was done prior to (7 days), during (28 days), and after treatment (7 days). The mean scores (last 3 treatment days) of the subscale ReQuest(TM)-GI (gastrointestinal complaints) were compared between both groups. After the end of treatment, the number of symptom episodes and the rate of relapses were calculated.

RESULTS

Noninferiority of pantoprazole versus esomeprazole during treatment was shown (mean ReQuest-GI score). During the posttreatment period, the proportion of patients experiencing a symptomatic relapse (51 vs. 61%, p = 0.0216, ITT) and the number of symptom episodes (0.56 vs. 0.74, p = 0.0095, ITT) were significantly lower on pantoprazole than on esomeprazole.

CONCLUSIONS

Pantoprazole 40 mg was at least as effective as esomeprazole 40 mg for relieving GERD symptoms. During the posttreatment phase, patients on pantoprazole had a significantly lower risk to relapse and experienced significantly fewer symptom episodes.

Novel measurement of rapid treatment success with ReQuest: first and sustained symptom relief as outcome parameters in patients with endoscopy-negative GERD receiving 20 mg pantoprazole or 20 mg esomeprazole

BACKGROUND/AIMS

A prime concern for gastroesophageal reflux disease (GERD) patients is fast symptom control. Sparse valid information is available on the rapidity of the effect of proton pump inhibitors in providing symptom relief. The new reflux questionnaire ReQuest is validated for daily assessment of changes in GERD symptoms. Therefore, this study investigated the efficacy of 20 mg pantoprazole and 20 mg esomeprazole with regard to the time to symptom relief in patients with endoscopy-negative GERD (enGERD) using ReQuest.

METHODS

529 patients were treated with pantoprazole or esomeprazole over 4 weeks. ReQuest symptom scores were assessed daily. The mean and median times to first and sustained symptom relief were determined.

RESULTS

Median time to first symptom relief was 2 days for both drugs (intention-to-treat population). The median time to sustained symptom relief was 3 days shorter with pantoprazole (10.0 vs. 13.0 days). The Hodges-Lehmann estimator for the difference in time to reach first and sustained symptom relief between both groups was 0.00 days. For both variables the one-sided 95% CI (Moses) was [0.00; infinity[, documenting no significant differences between the treatment groups.

CONCLUSIONS

The rapidity of symptom control can be evaluated by clinically significant parameters using ReQuest. Pantoprazole and esomeprazole are equally effective in the time to first and sustained symptom relief.

[Different courses of esomeprazole-based triple therapy for Helicobactor pylori infection in children]

OBJECTIVE

To study the efficacy of esomeprazole-based 1 week or 2 weeks triple therapy for Helicobactor pylori (H. pylori) infection in children.

METHODS

One hundred and five children with H. pylori infection identified by 13C-UBT were randomly assigned into Group A (n=60) and Group B (n=45). The patients of the two groups were administered with 1 week or 2 weeks triple therapy consisting of esomeprazole, clarithromycin and amoxillin, respectively. They were followed up four weeks after drug withdrawal.

RESULTS

Recurrent abdominal pain was relieved in all of patients. Fifty-five patients (91.7%) showed 13C-UBT negative in Group A and 42 (93.3%) presented negative in Group B. There was no significant difference in the eradication rate of H. pylori.

CONCLUSIONS

Esomeprazole-based triple therapy for H. pylori infection is effective in children. The efficacy of esomeprazole-based 1 week or 2 weeks triple therapy for this disorder does not appear to be different.

Maintenance treatment with esomeprazole following initial relief of non-steroidal anti-inflammatory drug-associated upper gastrointestinal symptoms: the NASA2 and SPACE2 studies

Non-steroidal anti-inflammatory drugs (NSAIDs), including selective cyclo-oxygenase-2 (COX-2) inhibitors, cause upper gastrointestinal (GI) symptoms that are relieved by treatment with esomeprazole. We assessed esomeprazole for maintaining long-term relief of such symptoms. Six hundred and ten patients with a chronic condition requiring anti-inflammatory therapy who achieved relief of NSAID-associated symptoms of pain, discomfort, or burning in the upper abdomen during two previous studies were enrolled and randomly assigned into two identical, multicentre, parallel-group, placebo-controlled studies of esomeprazole 20 mg or 40 mg treatment (NASA2 [Nexium Anti-inflammatory Symptom Amelioration] and SPACE2 [Symptom Prevention by Acid Control with Esomeprazole] studies; ClinicalTrials.gov identifiers NCT00241514 and NCT00241553, respectively) performed at various rheumatology, gastroenterology, and primary care clinics. Four hundred and twenty-six patients completed the 6-month treatment period. The primary measure was the proportion of patients with relapse of upper GI symptoms, recorded in daily diary cards, after 6 months. Relapse was defined as moderate-to-severe upper GI symptoms (a score of more than or equal to 3 on a 7-grade scale) for 3 days or more in any 7-day period. Esomeprazole was significantly more effective than placebo in maintaining relief of upper GI symptoms throughout 6 months of treatment. Life-table estimates (95% confidence intervals) of the proportion of patients with relapse at 6 months (pooled population) were placebo, 39.1% (32.2% to 46.0%); esomeprazole 20 mg, 29.3% (22.3% to 36.2%) (p = 0.006 versus placebo); and esomeprazole 40 mg, 26.1% (19.4% to 32.9%) (p = 0.001 versus placebo). Patients on either non-selective NSAIDs or selective COX-2 inhibitors appeared to benefit. The frequency of adverse events was similar in the three groups. Esomeprazole maintains relief of NSAID-associated upper GI symptoms in patients taking continuous NSAIDs, including selective COX-2 inhibitors.

Effect of timing of dosing in relation to food intake on the pharmacokinetics of esomeprazole

AIM

To investigate the pharmacokinetics of esomeprazole before a high-fat meal vs. fasting.

METHODS

This open-label, randomized, crossover study consisted of two 5-day dosing periods of esomeprazole 40 mg per day. On days 1 and 5, subjects received esomeprazole 15 min before a high-fat meal (fed) or 4 h before a non-high-fat meal (fasting).

RESULTS

On days 1 and 5, ratio of fed to fasting area under the plasma concentration-time curve [0.56, 90% confidence interval (CI) 0.50, 0.64, and 0.78, 90% CI 0.74, 0.82, respectively] and peak plasma concentration (0.34, 90% CI 0.28, 0.41, and 0.47, 90% CI 0.41, 0.52, respectively) were outside of the limits of bioequivalence.

CONCLUSIONS

Esomeprazole bioavailability was reduced when taken within 15 min before eating a high-fat meal vs. that while fasting.

Tegaserod for dyspepsia and reflux symptoms in patients with chronic constipation: an exploratory open-label study

OBJECTIVE

To evaluate the potential role of tegaserod in the management of functional dyspepsia (FD) and gastroesophageal reflux disease (GERD) in patients with chronic constipation and to determine the possible efficacy of tegaserod on solid-phase gastric emptying and gastric hypersensitivity.

METHOD

This was an exploratory open-label trial of tegaserod therapy for dyspepsia and reflux symptoms in patients with chronic constipation. The study cohort consisted of 90 patients randomized to three treatment groups for a study period of 4 weeks (tegaserod 6 mg, twice daily; esomeprazole 40 mg, once daily; tegaserod 6 mg, twice daily plus esomeprazole 40 mg, once daily). Twenty healthy volunteers provided control values. Clinical symptoms were evaluated by one of the investigators using a Gastrointestinal Symptom Rating Scale (GSRS). Solid-phase gastric emptying and colonic transit were measured by the radiopaque barium marker method, and the water load test (WLT) was used to evaluate gastric sensation and the function of proximal stomach. The proportions of patients with complete relief of epigastric pain /discomfort, epigastric fullness, early satiety and heartburn in the tegaserod group and the tegaserod plus esomeprazole group were compared with the esomeprazole group, respectively.

RESULTS

The mean global gastrointestinal (GI) scores of all three treatment groups reported using the GSRS showed the same trend, with decreasing scores over the 4-week study period indicating a reported decreasing severity of symptoms that was significantly different from baseline values. Patients in the tegaserod plus esomeprazole group reported the lowest global GI scores after 4 weeks, as expected. Solid-phase gastric emptying (GER) and colonic transit (CTT) increased significantly in the tegaserod 6 mg twice daily group compared with baseline. These parameters did not change in the esomeprazole group at week 4 compared with baseline. In terms of gastric sensation, in the tegaserod group, the proportions of patients with hypersensitivity of the first perception threshold did not change at week 2 or week 4 compared with baseline; however, in this group and in the tegaserod plus esomeprazole group, the proportions of patients with hypersensitivity of discomfort threshold decreased significantly at week 4 compared with baseline. In the esomeprazole group, there were no changes in the proportions of patients with hypersensitivity of the first perception threshold and discomfort threshold at week 2 or 4 compared with baseline. No severe adverse events were recorded, and the medications were in general well-tolerated.

CONCLUSION

Tegaserod is effective and safe at improving dyspepsia and reflux symptoms in patients with chronic constipation, and tegaserod plus esomeprazole is superior to esomeprazole alone in the resolution of epigastric pain/discomfort and heartburn.

Therapiekontrolle bei laryngopharyngealem Reflux durch wiederholte 2-Kanal-pH-Metrie

OBJECTIVES

The most effective current treatment option for patients suffering from laryngopharyngeal reflux (LPR) is the use of proton pump inhibitors (PPIs). Compared to other PPIs, esomeprazole seems to provide best 24-h control of intragastric acid. However, some patients remain resistant to medical acid suppression with PPIs. The aim of this investigation was to identify the number of non-responders among patients suffering from LPR being treated by esomeprazole 40 mg once daily (officially approved maximum dosage).

PATIENTS AND METHODS

Between June 2004 and January 2006, 27 patients suffering from LPR diagnosed by dual-probe pH monitoring were treated with esomeprazole 40 mg once daily. After 13-54 days (mean 28 days) while still under PPI-treatment, the 24-h pH-study was repeated in order to control the effectiveness of therapy. Patients with at least a reduction of the reflux area index (RAI) compared to the result before treatment were categorized as responders. Furthermore, the number of patients with a measurable reduction of proximal reflux episodes under PPI-treatment was quantified.

RESULTS

Repeated pH monitoring during PPI therapy revealed a reduction of the RAI in 22 of 27 patients. Five patients, however, showed a higher RAI despite medical treatment (19%). In 13 patients (48%), treatment with 40 mg esomeprazole once daily reduced the RAI to a normal value (<6.3). In 18 of 27 patients, the number of proximal reflux episodes has decreased (67%).

CONCLUSION

In a number of patients suffering from LPR, treatment with esomeprazole 40 mg once daily did not provide any measurable proximal acid reduction. Repeated pH monitoring during treatment is an adequate diagnostic tool to control the therapeutic effect of PPIs objectively and to identify non-responders at an early point.

Pharmacokinetic properties of esomeprazole in children aged 1 to 11 years with symptoms of gastroesophageal reflux disease: a randomized, open-label study

OBJECTIVE

The aim of this study was to assess the overall exposure, other pharmacokinetic (PK) properties, and tolerability of esomeprazole magnesium after repeated oral doses of 5, 10, and 20 mg in pediatric patients who had symptoms of gastroesophageal reflux disease (GERD).

METHODS

This randomized, open-label study was conducted at West Coast Clinical Trials, Long Beach, California. Boys and girls aged 1 to 11 years who had a clinical diagnosis of GERD were included and stratified by age (1-5 years [younger group] and 6-11 years [older group]). For this 5-day study, children in the younger group were randomly assigned to receive 1 esomeprazole 5- or 10-mg capsule p.o. QD, and those in the older group were randomly assigned to receive 1 esomeprazole 10- or 20-mg capsule p.o. QD. On days 1 to 4, study medications were administered with the supervision of the study personnel 1 hour before breakfast. Blood samples were collected within 0.5 hour before and 0.5, 1, 1.5, 2, 3, 4, 5, and 6 hours after study drug administration on day 5. Plasma concentrations of esomeprazole were measured using reverse-phase liquid chromatography and mass-spectrometric detection. Tolerability assessments were performed by reviewing the number and severity of adverse events (collected via spontaneous reporting and direct questioning) and findings from the physical examination, which included vital-sign measurements and laboratory analysis (hematology, biochemistry, and urinalysis). Site personnel supervised the administration of the study drug to ensure compliance with treatment.

RESULTS

The study included 31 children (17 boys, 14 girls; mean age, 5 years; 18 children in the younger group, 13 in the older group). A total of 27 children were included in the PK analysis. In the younger group, the geometric mean AUC(0-infinity) and Cmax values in the esomeprazole 10-mg group were >2-fold that in the 5-mg group (AUC(0-infinity), 4.83 and 0.74 pmol x h/L [0.32 and 0.04 micromol x h x L(-1)/kg], respectively; Cmax, 2.98 and 0.62 micromol/L [0.19 and 0.03 micromol/L x kg(-1)], respectively). In the older group, the geometric mean AUC(0-infinity) and Cmax values for the 20-mg dose group were approximately 2-fold those for the 10-mg dose group (AUC(0-infinity), 6.28 and 3.70 micromol x h/L [0.21 and 0.12 pmol x h x L(-1)/kg], respectively; Cmax, 3.73 and 1.77 micromol/L [0.13 and 0.06 micromol/L x kg 1], respectively). For the 10-mg esomeprazole dose, the geometric mean body-weight-normalized apparent oral clearance was approximately 50% higher in the younger group compared with the older group (0.40 and 0.25 L/h x kg(-1), respectively). Thirty patients were included in the tolerability analysis. The adverse events that occurred were skin excoriation, discolored feces, and skin laceration (1 [3.3%] patient each); none were considered related to treatment.

CONCLUSIONS

The results of this small study suggest that, in children aged 1 to 11 years who had GERD, the PK properties of esomeprazole may be both dose and age dependent and that younger children might have a more rapid metabolism of esomeprazole per kilogram of body weight compared with older children. Esomeprazole was well tolerated at doses of 5, 10, and 20 mg in the pediatric patients studied.

Acidic and Non-Acidic Reflux During Sleep Under Conditions of Powerful Acid Suppression

BACKGROUND

During sleep, individuals are uniquely vulnerable to acid reflux. Acid reflux during sleep has been studied by a number of investigators, but non-acid reflux is largely unexplored.

METHODS

In this study, 15 individuals with significant subjective complaints of heartburn were treated with esomeprazole, 40 mg bid, and with placebo, in random order, for 1 week each. After 1 week of treatment, participants underwent combined impedence/pH monitoring and polysomnography. In both drug and placebo conditions, these procedures were done after participants consumed a meal designed to increase the likelihood of reflux events.

RESULTS

Total reflux events and acid reflux events were significantly decreased with proton-pump inhibitor (PPI) treatment as compared to placebo. Nonacid reflux events were more common with PPI treatment as compared to placebo, but this result was not statistically significant. The ratio of non-acidic to acidic events was significantly greater with PPI treatment, however. Similar results were found for reflux events that occurred only during sleep. Proximal migration of acidic vs non-acidic reflux events was found to be similar. There was no difference in sleep architecture between placebo and drug conditions.

CONCLUSION

PPI treatment reduced overall reflux events, but non-acidic reflux events were relatively more likely to occur with PPI treatment. The occurrence of these non-acidic reflux events on PPI might conceivably explain why some individuals continue to have symptoms after PPI treatment.

Acid control with esomeprazole and lansoprazole: a comparative dose-response study

OBJECTIVE

To determine the level of acid control and the dose-response relationships achieved with esomeprazole and lansoprazole. These data are relevant in helping clinicians to decide on whether to increase a proton-pump inhibitor dose, or whether to switch to an alterative drug for increased acid control.

MATERIAL AND METHODS

In an open-label, single-centre, randomized, six-way crossover study, 40 healthy subjects received esomeprazole 20, 40 and 80 mg, and lansoprazole 15, 30 and 60 mg once daily for 5 days. The mean time with intragastric pH >4 and mean 24-h median intragastric pH on day 5 were analyzed using a mixed-model ANOVA. Post-hoc analyses were completed for 0-12-h (daytime) and 12-24-h (night-time) post-dose intervals.

RESULTS

Increasing the dose of esomeprazole from 20 mg to 40 mg resulted in significantly improved acid control over 0-12, 12-24 and 0-24 h post-dose (p<0.001), but no significant improvement in acid control for either period was seen when further increasing the dose to 80 mg. Increasing the dose of lansoprazole from 15 mg to 30 mg or from 30 mg to 60 mg significantly improved acid control over 0-12 and 0-24 h (p<0.01) but not over 12-24 h. With the exception of the esomeprazole 20 mg versus lansoprazole 30 mg comparisons, and the esomeprazole 20 mg versus lansoprazole 15 mg during 12-24 h post-dose comparison, esomeprazole provided significantly greater acid control than lansoprazole at each dose level over 0-12, 12-24 and 0-24 h (p<0.05). Mean 24-h median intragastric pH was higher following esomeprazole dosing compared with lansoprazole at each dose level.

CONCLUSIONS

For low-, standard- and double-dose comparisons, esomeprazole achieved greater elevation of gastric pH and better acid control in more subjects than lansoprazole. Use of esomeprazole may therefore reduce the need for dose adaptations or drug switching.

[Efficiency and safety of the intravenous application of esomeprazole (nexium - Astra Zeneca) in high risk patients subjected to mechanic ventilation]

INTRODUCTION

The aim of the research was to determine the effectivity and the safety of the intravenous application of Esomeprazole (Nexium - Astra Zeneca) like prevention of the development of stress-ulcers of the gastric mucous with high risk patients at ICU with mechanic ventilation.

PATIENTS AND METHODS

47 patients subjected to mechanic ventilation over 48 hours with availability of just one more risk factor for development of stress-ulcers of gastric musous were included in the study. Samples of gastric juice for determination of the acidity and presence of fresh erythrocytes and microbiological cultures from gastric contents, wash away of the mouth cavity and tracheal aspiration were tested on the 1st, the 3rd and the 5th day from the start of the treatment. At the end of the therapy there has been determinated the outcome - survivor or died and total quantity of the haemotransfusions.

RESULTS

The acidity of the gastric juice changed in the range over pH 5 during the 24 hours by the application of esomeprazole. Fibrogastroscopic examinations were performed of patients who were found to have fresh erythrocytes in the gastric contents. No one was registered with bleeding of the gastric mucous. The isolated microorganisms of the gastric juice and wash away of mouth cavity were identical with those of tracheobronchial aspiration in about 13 %.

CONCLUSIONS

In our study the application of esomeprazole i.v. was effective and safe approach for profilaxy of the stress-ulcers and the bleeding of the gastric mucous. Comparative studies with H2-blockers and sucralfat are necessary for clarifying and objectifying the significance of the microbiologic isolates of the gastric contents and wash away from mouth cavity and their relation to the development of nosocomial pneumonia.

Effect of oral esomeprazole on recurrent bleeding after endoscopic treatment of bleeding peptic ulcers

BACKGROUND

After endoscopic treatment of bleeding peptic ulcer, a high-dose infusion of omeprazole substantially reduces the risk of recurrent bleeding. The role of oral proton pump inhibitors for these patients is uncertain. The purpose of the present study was to assess whether the use of oral esomeprazole would reduce the frequency of recurrent bleeding after endoscopic treatment of bleeding peptic ulcers.

METHODS

Patients with actively bleeding ulcers or ulcers with non-bleeding visible vessels were treated with an epinephrine injection followed by thermocoagulation. After hemostasis had been achieved, they were randomly assigned in a double-blind fashion to receive esomeprazole (40 mg p.o. twice daily for 3 days) or placebo. The outcome measures studied were recurrent bleeding, blood transfusion requirement, surgery and death.

RESULTS

A total of 70 patients were enrolled, 35 in each group. Bleeding recurred within 30 days in two patients (5.7%) in the esomeprazole group, as compared with three (8.6%) in the placebo group (P = 0.999). Blood transfusion requirement was 2.8 +/- 1.4 units in the esomeprazole group and 2.7 +/- 1.3 units in the placebo group (P = 0.761). Duration of hospitalization was 4.82 +/- 1.8 days in the esomeprazole group and 4.58 +/- 2.7 days in the placebo group (P = 0.792). No patients needed surgery for control of bleeding and no patients died in both groups.

CONCLUSIONS

After successful endoscopic treatment of bleeding peptic ulcer, oral use of esomeprazole might offer no additional benefit on the risk of recurrent bleeding.