Impact of nocturnal heartburn on quality of life, sleep, and productivity: the SINERGE study

Associations between bedtime eating or drinking, sleep duration and wake after sleep onset: findings from the American time use survey

Sleep hygiene recommendations discourage eating before bedtime; however, the impact of mealtime on sleep has been inconsistent. We examined gender-stratified associations between eating or drinking <1, <2 and <3 h before bedtime, sleep duration and wake after sleep onset (WASO >30 min). This study utilised 2003-2018 data from the American Time Use Survey, a nationally representative sample of USA residents aged ≥15 years. Participants recorded weekday/weekend activities during a 24-h period. Age-specific sleep duration and WASO were estimated categorically and continuously. Eating or drinking were identified from all activities recorded <1, <2 and <3 h before bedtime. Mean ± se sleep duration was 8·0 ± 0·006 h, and 6% of participants ate or drank <1 h prior to weekdays bedtime. Overall, eating or drinking <1 h prior to bedtime was associated with longer weekdays sleep duration. Women and men who ate or drank <1 h before bedtime, v. those who did not, had 35 min (95% CI (30,39)) and 25 min (95 % CI (21,29)) longer sleep duration, respectively, as well as increased odds of WASO; women (OR=2·03, 95% CI (1·66,2·49)) and men (OR=2·64, 95% CI (2·08,3·36)). As the interval of eating or drinking prior to bedtime expanded, odds of short and long sleep durations and WASO decreased. This population-based data linked eating or drinking <1 h before bedtime to longer sleep duration, but increased WASO. Eating or drinking further from bedtime lowers the odds of short and long sleep duration and WASO. Causal pathways are difficult to discern, though inefficient sleep after late-night eating could increase WASO and trigger compensatory increases in sleep duration.

Gastro-oesophageal reflux disease

Gastro-oesophageal reflux disease (GERD) is a common disorder in adults and children. The global prevalence of GERD is high and increasing. Non-erosive reflux disease is the most common phenotype of GERD. Heartburn and regurgitation are considered classic symptoms but GERD may present with various atypical and extra-oesophageal manifestations. The pathophysiology of GERD is multifactorial and different mechanisms may result in GERD symptoms, including gastric composition and motility, anti-reflux barrier, refluxate characteristics, clearance mechanisms, mucosal integrity and symptom perception. In clinical practice, the diagnosis of GERD is commonly established on the basis of response to anti-reflux treatment; however, a more accurate diagnosis requires testing that includes upper gastrointestinal tract endoscopy and reflux monitoring. New techniques and new reflux testing parameters help to better phenotype the condition. In children, the diagnosis of GERD is primarily based on history and physical examination and treatment vary with age. Treatment in adults includes a combination of lifestyle modifications with pharmacological, endoscopic or surgical intervention. In refractory GERD, optimization of proton-pump inhibitor treatment should be attempted before a series of diagnostic tests to assess the patient's phenotype.

Rapid resolution of sleep disturbances related to frequent reflux: effect of esomeprazole 20 mg in two randomized, double-blind, controlled trials

OBJECTIVE

To investigate the resolution of heartburn and gastroesophageal reflux disease (GERD)-related sleep disturbances during the first 14 days of treatment with esomeprazole 20 mg compared to placebo in subjects with frequent nighttime heartburn and GERD-related sleep disturbances.

RESEARCH DESIGN AND METHODS

This was a post hoc analysis of 2 week data from two previously published, similarly designed randomized, placebo-controlled trials of 4 weeks' duration comparing esomeprazole 20 mg, 40 mg (one study), and placebo. Inclusion and exclusion criteria for both trials were the same.

CLINICAL TRIAL REGISTRATION

NCT00628342; NCT00660660.

MAIN OUTCOME MEASURES

The main outcome measures for this analysis were the resolution and/or relief of GERD-related sleep disturbances during 2 weeks of treatment with esomeprazole 20 mg or placebo. Resolution and/or relief of heartburn symptoms were also measured.

RESULTS

In trial 1, 455 subjects were randomized, with 225 and 229 receiving esomeprazole 20 mg and placebo, respectively. In trial 2, 276 subjects were randomized, with 142 and 132 receiving esomeprazole and placebo, respectively. After 2 weeks, significantly more subjects who received esomeprazole 20 mg (50.5% [95% confidence interval: 43.8%-57.1%] and 39.4% [31.2%-47.6%] in trials 1 and 2, respectively) had resolution of sleep disturbances compared to placebo (19.9% [14.6%-25.2%] and 16.0% [9.6%-22.4%], respectively; p < 0.0001 for both trials). The median time to resolution of sleep disturbances with esomeprazole 20 mg was 1 day in both trials. After 2 weeks, significantly more subjects receiving esomeprazole 20 mg (32.3% [26.1%-38.5%] and 26.3% [18.9%-33.6%] in trials 1 and 2, respectively) had resolution of nighttime heartburn symptoms compared to placebo (5.4% [2.4%-8.4%] and 4.8% [1.1%-8.5%], respectively; p < 0.0001 for both trials).

CONCLUSIONS

Esomeprazole 20 mg significantly and effectively reduced nighttime heartburn and GERD-related sleep disturbances in the first 2 weeks of treatment compared to placebo, with rapid resolution of sleep disturbances in the first days of treatment.

Epidemiology of reflux symptoms and GORD

Gastro-oesophageal reflux disease (GORD) occurs when reflux of gastric contents causes troublesome symptoms and/or complications (the Montreal definition). GORD is a common condition with a substantial economical burden to the community and it has a significant negative effect on health-related quality of life (HRQoL) while endoscopic findings like erosive oesophagitis per se seem to correlate badly with the experienced HRQoL. The prevalence of GORD varies over the world for unknown reasons, but genetic differences, difference in the Helicobacter pylori prevalence and life style factors like obesity might influence. The prevalence is lowest in East Asia (2.5-9.4%) and higher in Mid (7.6-19.4%) and Western Asia (12.5-27.6%). The highest population-based prevalence is reported from Europe (23.7%) and the US (28.8%). GORD seems to be fairly stable over time both in terms of symptoms and erosive oesophagitis, but the prevalence seems to be increasing both in Asia and in the West.

Gastroesophageal reflux disease: impact on work productivity and daily-life activities of daytime workers. A French cross-sectional study

BACKGROUND

Few studies have evaluated the impact of gastroesophageal reflux disease symptoms on work productivity and no French data are available.

AIM

To compare the impact of typical symptoms of nocturnal vs diurnal gastroesophageal reflux disease on work productivity and daily activities.

METHODS

A French prospective, multicenter, observational study was performed in primary care setting. Patient characteristics, symptomatology and treatment were reported. Work productivity loss was assessed using the work productivity and activity impairment questionnaire, predictors were identified using multivariate regression models, and estimated cost was calculated.

RESULTS

716 eligible patients (mean age: 46.3 years) were included by 407 physicians. Nocturnal symptoms were reported in 50.8% of patients and exclusively diurnal symptoms in 49.2%. Mean work productivity and daily activities decreased by 31.4% and 32.6%, respectively (both p<0.001). Work productivity was influenced by symptom intensity, diurnal symptoms occurrence, regurgitation and diurnal sleepiness. The mean associated cost per patient/week (€313) was higher in patients with diurnal symptoms (without (€346) or with nocturnal (€312) symptoms) than in patients with exclusive nocturnal symptoms (€253) (p<0.001).

CONCLUSION

Gastroesophageal reflux disease incurs high work productivity loss especially in patients with diurnal symptoms. Further medico-economic analyses are needed to estimate the cost effectiveness ratio according to therapeutic strategies.

Systematic review: the burden of disruptive gastro-oesophageal reflux disease on health-related quality of life

BACKGROUND

About one-third of patients with gastro-oesophageal reflux disease (GERD) have frequent and/or severe reflux symptoms ('disruptive GERD'). The relative burden of disruptive GERD on health-related quality of life (HRQL) has not been systematically investigated.

AIM

To assess the burden of disruptive vs. nondisruptive GERD on HRQL.

METHODS

Systematic searches were conducted in PubMed and Embase. To be included, studies had to have used validated questionnaires to assess HRQL.

RESULTS

Nineteen studies were included. Data on the comparative burden of frequent (ranging from daily to ≥weekly) and severe reflux symptoms were provided in eight and 13 studies respectively; six reported on the additional burden of nocturnal symptoms. Compared with individuals with nondisruptive GERD, those with disruptive GERD had 2.4-times and 1.5-times higher mean rates of absenteeism and presenteeism respectively (five studies), 1.5-times lower sleep quality scores (three studies), 1.1-times lower mean summary scores for physical and mental health (five studies) and 1.3-times lower mean scores for psychological and general well-being (four studies). Increasing symptom frequency and severity both increased the burden of disease to a similar extent. The presence of nocturnal symptoms in addition to daytime symptoms led to worsening of physical health, but their effect on mental health and work productivity was less clear.

CONCLUSIONS

Disruptive GERD is associated with a high burden of disease compared with occasional or mild reflux symptoms. Disease management needs to vary across the GERD spectrum and should be tailored to patients' requirements for optimal therapeutic outcomes.

Work productivity and activity impairment in gastroesophageal reflux disease in Korean full-time employees: a multicentre study

INTRODUCTION

The costs of gastroesophageal reflux disease have not been assessed in Asia, even though the prevalence of gastroesophageal reflux disease is gradually increasing. We evaluated work presenteeism and absenteeism as indirect costs of gastroesophageal reflux disease in Korea.

METHODS

This was a cross-sectional and multicentre study using patient-reported outcome instruments. A total of 1009 full-time employees who visited the gastrointestinal department for any reason (281 patients with gastroesophageal reflux disease and 728 controls) were included. Main outcomes were presenteeism and absenteeism measured as work productivity loss and monetary cost per week.

RESULTS

Absenteeism and presenteeism were significantly higher in the gastroesophageal reflux disease than the control group (1.49% vs. 0.46%, P=0.0010; 34.13% vs. 9.23%, P<0.0001). Loss of work productivity was significantly greater in the gastroesophageal reflux disease than the control group (33.09% vs. 9.02%; P<0.0001). This loss of work productivity difference between the two groups represented an additional productivity loss of 11.7h/week in the gastroesophageal reflux disease group compared with the control group. Assuming average hourly wages of $14.12, the weekly burden of gastroesophageal reflux disease reached $165.07 per person.

CONCLUSIONS

Gastroesophageal reflux disease was associated with substantial work productivity loss, mainly due to presenteeism rather than absenteeism, in Korean full-time employees.

Prevalence of and impact of pantoprazole on nocturnal heartburn and associated sleep complaints in patients with erosive esophagitis

Studies in the United States have revealed that gastroesophageal reflux disease (GERD) patients often suffer from nocturnal symptoms, sleep disturbance, and impaired quality of life. In a large subset of patients, these symptoms persist in spite of acid suppressive therapy. The aim of the present study was to assess the prevalence of heartburn and associated sleep complaints and the response to standard medical therapy with pantoprazole in primary and secondary care esophagitis patients in Belgium. Questionnaires were provided to consecutive patients presenting to primary and secondary care physicians with esophagitis. The questionnaire evaluated the presence of typical reflux symptoms, alarm symptoms, risk factors, and sleep quality impairment as a result of reflux episodes. Results are shown as mean ± standard deviation and compared by Student's t-test or chi-square test. A total of 4061 primary and 5261 secondary care patients (50% female, mean age 53 ± 0.2 years, body mass index of 25.7 ± 0.1 kg/m(2) ) were recruited. Eighty-four percent of patients reported sleep disturbance attributable to nighttime reflux, including typical nighttime supine reflux symptoms (72%), difficulties to fall asleep (39%), waking up during the night (45%), morning fatigue (35%), and reflux symptoms when waking up in the morning (47%). Mild, moderate, or severe nighttime heartburn were reported by, respectively, 30, 35, and 12%, and these numbers were 26, 28, and 6% for nighttime regurgitation. Alcohol (19%), smoking (22%), higher esophagitis grades (grades 2, 3, and 4 in, respectively, 31, 7, and, 7%), alarm symptoms (27%), and more severe heartburn and regurgitation during daytime were all significantly associated with all dimensions of sleep disturbance (P < 0.0001). Obesity was only related to symptoms in supine position and when waking up (P < 0.0001). After 1.4 ± 0.0 months of treatment with pantoprazole, any sleep disturbance had improved in more than 75% of patients, with resolution of nighttime heartburn and regurgitation in, respectively, 75 and 83%. The majority of patients presenting with reflux symptoms and esophagitis in primary or secondary care experience nighttime heartburn and regurgitation, and sleep disturbance by nighttime symptoms is present in 84%. Smoking, alcohol use, higher grades of esophagitis, more severe typical reflux symptoms during daytime, and the presence of alarm symptoms are risk factors for GERD-related sleep disturbance. On standard therapy with pantoprazole, nighttime symptoms improved in more than 75%. These observations support a direct relationship between GERD and sleep disturbance.

[Use of health resources and loss of productivity in gastroesophageal reflux disease: results of a cross-sectional study in a primary care setting in Spain]

OBJECTIVE

To evaluate healthcare resource use and productivity in patients with gastro-esophageal reflux disease (GERD) and the influence of disease severity on these two factors.

DESIGN

Sub-analysis of the Spanish population of a multinational study with a 4-month retrospective period for the identification and selection of patients, and a clinical visit to obtain clinical information and data on use of healthcare resources, carried out between October 2007 and January 2008.

POPULATION

A total of 477 patients attending a Primary Care centre, with a medical consultation for GERD.

MAIN VARIABLES

Use of healthcare resources, changes in productivity based on the Work Productivity and Activity Impairment Questionnaire for GERD patients (WPAI-GERD).

RESULTS

Despite having received pharmacological treatment at the baseline visit, after a median of 5.1 months follow-up (range 2.1-8.1), up to 15.9% (95% CI; 12.8-19.5) patients still showed clinically relevant GERD symptoms. Direct medical costs per year associated with diagnostic tests and medical consultations in patients with or without clinically relevant GERD symptoms were 666 € (SD: 2,097 €) and 370 € (SD: 2,060 €), respectively. The mean annual cost of reduced productivity (17%) was 5,316 € (SD: 8,615 €). This cost was 4 times higher for patients with clinically relevant GERD symptoms than for patients with no relevant symptoms (15,188 € [SD: 11,206 €] vs 3,926 € [SD: 7,232 €]).

CONCLUSION

Patients with GERD use significant healthcare resources, attributable to associated medical costs and marked reduction in productivity, even though they receive pharmacological treatment.

The effect of dexlansoprazole MR on nocturnal heartburn and GERD-related sleep disturbances in patients with symptomatic GERD

OBJECTIVES

Nocturnal heartburn and related sleep disturbances are common among patients with gastroesophageal reflux disease (GERD). This study evaluated the efficacy of dexlansoprazole MR 30 mg in relieving nocturnal heartburn and GERD-related sleep disturbances, improving work productivity, and decreasing nocturnal symptom severity in patients with symptomatic GERD.

METHODS

Patients (N=305) with frequent, moderate-to-very severe nocturnal heartburn and associated sleep disturbances were randomized 1:1 in a double-blind fashion to receive dexlansoprazole MR or placebo once daily for 4 weeks. The primary end point was the percentage of nights without heartburn. Secondary end points were the percentage of patients with relief of nocturnal heartburn and of GERD-related sleep disturbances over the last 7 days of treatment. At baseline and week 4/final visit, patients completed questionnaires that assessed sleep quality, work productivity, and the severity and impact of nocturnal GERD symptoms.

RESULTS

Dexlansoprazole MR 30 mg (n=152) was superior to placebo (n=153) in median percentage of nights without heartburn (73.1 vs. 35.7%, respectively; P<0.001). Dexlansoprazole MR was significantly better than placebo in percentage of patients with relief of nocturnal heartburn and GERD-related sleep disturbances (47.5 vs. 19.6%, 69.7 vs. 47.9%, respectively; P<0.001), and led to significantly greater improvements in sleep quality and work productivity and decreased nocturnal symptom severity. Adverse events were similar across treatment groups.

CONCLUSIONS

In patients with symptomatic GERD, dexlansoprazole MR 30 mg is significantly more efficacious than placebo in providing relief from nocturnal heartburn, in reducing GERD-related sleep disturbances and the consequent impairments in work productivity, and in improving sleep quality/quality of life.

[Study of the clinical profile and management of patients with gastroesophageal reflux disease in primary care in Spain]

OBJECTIVE

To assess the clinical profile and management of patients with gastroesophageal reflux disease (GERD) in primary care.

METHODS

A multinational, multicenter study was performed comprising a 4-month retrospective phase for the screening, selection and assessment of patients who had consulted for any GERD-related cause (index visit), and a cross-sectional phase in which clinical data were recorded and the following questionnaires were administered: the Reflux Disease Questionnaire and the Gastroesophageal Reflux Disease Impact Scale (GIS).

RESULTS

Among the 24 participating Spanish centers, 2.7% of the patients (95% CI: 2.6-2.9) had consulted at least once because of GERD. Approximately 50% of the patients showed frequent (2 or more days a week) or moderate to severe symptoms of heartburn, acid regurgitation or chest pain. Although the patients received effective pharmacological treatment at the index visit, clinically relevant GERD symptoms persisted in 16% after a median follow-up of 5 months. These symptoms were associated with a strong disease impact as evaluated with the GIS.

CONCLUSION

GERD represents a substantial burden for primary care physicians. Although effective drugs are used for the treatment of this condition, clinically relevant symptoms persist in a substantial proportion of patients.

Impact of gastro-oesophageal reflux disease on work productivity despite therapy with proton pump inhibitors in Germany

BACKGROUND

Gastro-oesophageal reflux disease (GERD) is a common disorder with consequences for the patient's health-related quality of life (HRQoL). In Germany, few data are available on the impact of GERD on work-related productivity.

AIM

To study the impact of GERD on work productivity despite proton pump inhibitor (PPI) therapy and the association between productivity and symptom duration, severity, and HRQoL.

METHODS

Retrospective data from randomly selected patients with chronic GERD symptoms, treated by office-based general practitioners or general internists with routine clinical care, were analyzed together with information from self-administered instruments assessing work productivity (WPAI-GERD), symptoms (RDQ), and HRQoL (QOLRAD).

RESULTS

Reduced productivity was reported by 152 of 249 patients (61.0%), although 89.5% of them were treated with PPI. The reduction in work productivity was 18.5% in all patients and 30.3% in those with reduced productivity. Patients with impaired productivity showed a significantly lower HRQoL and more-severe symptoms of reflux disease. In all patients, the mean sick leave attributable to reflux symptoms was 0.6 hours in the previous seven days and 1.4 work days in the previous three months.

CONCLUSION

GERD has a substantial impact on work productivity in Germany, even in patients receiving routine clinical care and PPI therapy.

Role of the primary care provider in the diagnosis and management of heartburn

BACKGROUND

Heartburn affects an estimated 42% of the US population. Often, patients are able to recognize symptoms and self-treat heartburn; however, patients with more persistent and/or troublesome symptoms should be evaluated by a physician or other healthcare provider.

SCOPE

This review focuses on the role of the primary care provider in the diagnosis and treatment of heartburn.

METHODS

A search was conducted on PubMed (to November 2009) and articles relevant to the management of heartburn by a primary care provider topic were selected.

FINDINGS

Diagnostic tools, such as endoscopy, and ambulatory pH monitoring, are recommended for advanced assessment of patients with frequent heartburn to avert misdiagnosis and to identify complications of reflux disease. Over-the-counter and prescription treatments for frequent heartburn symptoms include antacids, histamine(2)-receptor antagonists (H(2)RAs), antacid/H(2)RA combinations, and proton pump inhibitors (PPIs). Among these, PPIs represent the mainstay of acute and maintenance treatment regimens in reflux disorders and are more effective than H(2)RAs for long-term use due to the development of tolerance to the latter therapy. While once-daily PPI therapy may be sufficient in most patients, a few may require twice-daily PPI therapy to alleviate their symptoms. This review is limited by its relatively narrow focus on articles cited in PubMed.

CONCLUSION

The primary care provider is ideally situated to advise patients on the best treatment option for their condition and to provide follow-up care if required.

Construct validity of the Work Productivity and Activity Impairment questionnaire across informal caregivers of chronically ill older patients

OBJECTIVES

To assess the validity of the Work Productivity and Activity Impairment questionnaire as adapted for caregiving (WPAI:CG) to measure productivity loss (hours missed from work, impairment while at work, and impairment in regular activities) due to unpaid caregiving for medically complex older adults.

METHODS

The WPAI:CG was administered along with the Caregiver Strain Index (CSI) and Center for Epidemiologic Studies Depression Scale (CESD) to a caregiving population (N = 308) enrolled with their older, medically complex care-recipient in a cluster-randomized controlled study. Correlation coefficients were calculated between each productivity variable derived from the WPAI:CG and CSI/CESD scores. Nonparametric tests for trend across ordered groups were carried out to examine the relationship between each productivity variable and the intensity of the caregiving.

RESULTS

Significant positive correlations were found between work productivity loss and caregiving-related strain (r = 0.45) and depression (r = 0.30). Measures of productivity loss were also highly associated with caregiving intensity (P < 0.05) and care-recipient medical care use (P < 0.05). The average employed caregiver reported 1.5 hours absence from work in the previous week and 18.5% reduced productivity while at work due to caregiving. Employed and nonemployed caregivers reported 27.2% reduced productivity in regular activities in the previous week.

CONCLUSION

The results indicate high convergent validity of the WPAI:CG questionnaire. This measure could facilitate research on the cost-effectiveness of caregiver-workplace interventions and provide employers and policy experts with a more accurate and comprehensive estimate of caregiving-related costs incurred by employers and society.

[Validation of the Reflux Disease Questionnaire (RDQ) and Gastrointestinal Impact Scale (GIS) in patients with gastroesophageal reflux disease in the Spanish population]

OBJECTIVES

To assess the feasibility, reliability, validity and sensitivity of changes in the Reflux Disease Questionnaire (RDQ) and the Gastrointestinal Impact Scale (GIS).

MATERIAL AND METHODS

An observational, prospective, multicenter study was conducted in primary care centers on two visits (baseline and 16 days later) in a sample of patients with a diagnosis of gastroesophageal reflux disease (GERD) or suspicion of GERD requiring a therapeutic intervention (sensitivity to change group, n=230) and in another sample of patients with clinically controlled GERD (reliability group, n=51).

RESULTS

The RDQ questionnaire and GIS scale, both overall and for each domain, showed a Cronbach's alpha of greater than or equal to 0.70. All RDQ domains and the total score, as well as the total GIS score and impact dimension, showed a high correlation between the baseline evaluation and that performed 16 days later in stable patients. The RDQ and GIS showed very high correlations between the total scores and those of the quality of life in reflux and dyspepsia (QOLRAD) (-0.73 and 0.80, respectively), a reflux- and dyspepsia-specific quality of life scale, and a high correlation with the gastrointestinal symptoms rating scale (GSRS) (0.54 and -0.55, respectively), a general scale of gastrointestinal symptoms. Both the RDQ questionnaire and the GIS scale showed significant changes with a high effect size on improvement responses.

CONCLUSIONS

The RDQ and GIS questionnaires show very good psychometric properties, making them suitable for use in primary care.