Health-Related quality-of-life and quality-days incrementally gained in symptomatic nonerosive GERD patients treated with lansoprazole or ranitidine

The Role of a Plant-Only (Vegan) Diet in Gastroesophageal Reflux Disease: Online Survey of the Italian General Population

The relationship between food and the pathophysiological mechanisms of gastroesophageal reflux disease (GERD) is unclear. There are few data on the impact of dietary habits on GERD symptoms and on the incidence of GERD in subjects undergoing plant-based diets. In this study, we investigated the association between diet and GERD, using data collected through an online survey of the Italian general population. In total, 1077 subjects participated in the study. GERD was defined according to the Montreal Consensus. For all subjects age, gender, body mass index (BMI), marital status, education, occupation, alcohol consumption, and smoking habits were recorded. All participants also completed the SF-36 questionnaire on Quality of Life. A total of 402 subjects (37.3%) were vegans and 675 (62.7%) non-vegans. The prevalence of GERD in the total population was 9%. Subjects with GERD-related symptoms recorded a worse quality of life according to SF-36 analysis (p < 0.05 for all dimensions). In multivariate analysis, after adjusting for confounders, participants undergoing a vegan diet had a significantly lower risk of GERD (OR = 0.47, 95% CI 0.28-0.81, p = 0.006). These findings should be taken into account to inform the lifestyle management of GERD.

Effects of coexisting upper gastrointestinal symptoms on daily life and quality of life in patients with gastroesophageal reflux disease symptoms

BACKGROUND AND AIM

Gastroesophageal reflux disease (GERD) is a common disease encountered in daily medical care and clinical problem which hampers daily life and reduces quality of life (QOL). The coexistence of GERD-related symptoms with the typical GERD symptoms, such as heartburn or acid regurgitation, and various upper abdominal symptoms is frequently observed in patients with GERD. However, the effect of these coexisting symptoms on the daily life and QOL of patients with GERD has not been clarified. Therefore, the effects of the various upper abdominal symptoms coexisting with GERD on the daily life and QOL of such patients were compared.

METHODS

A total of 113 newly diagnosed patients who visited our hospital with typical GERD symptoms were assessed using the modified frequency scale for the symptoms of GERD (MFSSG), gastroesophageal reflux and dyspepsia therapeutic efficacy and satisfaction test (GERD-TEST), and short-form 8-item health survey (SF-8) questionnaires. The "gastroesophageal reflux symptom" (7 items) and "dyspepsia symptom" (7 items) groups were divided into two "typical symptoms" and two "atypical symptoms" for a total of four categories. The Pearson's correlation coefficient and multiple regression analysis were used to evaluate the correlations between each symptom category and dissatisfaction for daily life [eating, sleeping, daily activities, mood, as well as dissatisfaction for daily life-symptom subscale (SS), which is the average of the four items in the GERD-TEST, the physical component summary [PCS] and mental component summary [MCS] of the SF-8, and the influence of each symptom category on the daily life and QOL.

RESULTS

The incidences of each symptom category in patients with GERD were high: typical GERD (100%), atypical GERD symptoms (67.3%), typical functional dyspepsia (FD) (71.7%), and atypical FD (75.2%). Pearson's correlation analysis demonstrated significant correlations between each symptom category and living status (dissatisfactions of eating, sleeping, daily activities, daily life-SS) and almost all items in SF-8 (PCS, MCS) (P < 0.05). Multiple regression analysis indicated the largest influences of each symptom category on living status and QOL in descending order: dissatisfaction for eating (atypical FD, typical FD), daily activities (atypical FD, typical FD, typical GERD), mood (atypical FD), daily life-SS (atypical FD, typical FD), PCS (typical FD), and MCS (atypical FD) (P < 0.05).

CONCLUSION

Coexisting FD symptoms, particularly atypical FD symptoms, had a large influence on the impairments of daily life and decreases in QOL. Daily medical care of GERD requires attention to coexisting symptoms and their treatment instead of just focusing on the chief complaints by patients.

The Safety of Appropriate Use of Over-the-Counter Proton Pump Inhibitors: An Evidence-Based Review and Delphi Consensus

The availability of over-the-counter (OTC) proton pump inhibitors (PPIs) for the short-term (2 weeks) management of frequent heartburn (≥2 days/week) has increased markedly, yet evidence-based recommendations have not been developed. A panel of nine international experts in gastroesophageal reflux disease developed consensus statements regarding the risks and benefits of OTC PPIs using a modified Delphi process. Consensus (based on ≥80% approval) was reached through multiple rounds of remote voting and a final round of live voting. To identify relevant data, the available literature was searched and summarized. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system terminology was used to rate the quality of evidence and strength of recommendations; consensus was based on ≥2/3 agreement. After 4 rounds of review, consensus was achieved for 18 statements. Notably, the available data did not directly reflect OTC use, but instead, prescription use; therefore, extrapolations to the OTC setting were often necessary. This limitation is regrettable, but it justifies performing this exercise to provide evidence-based expert opinion on a widely used class of drugs. The panel determined that using OTC PPIs according to label instructions is unlikely to mask the symptoms of esophageal or gastric cancer or adversely impact the natural history of related precursor conditions. OTC PPIs are not expected to substantially affect micronutrient absorption or bone mineral density or cause community-acquired pneumonia, Clostridium difficile infection, or cardiovascular adverse events. However, OTC PPI use may be associated with slightly increased risks for infectious diarrhea, certain idiosyncratic reactions, and cirrhosis-related spontaneous bacterial peritonitis. The available evidence does not suggest that OTC PPI use consistent with label instructions is associated with substantial health risks. To minimize potential risks, healthcare professionals and consumers must actively participate in decision making when managing reflux-related symptoms in the self-care setting.

Proton pump inhibitors for the treatment of patients with erosive esophagitis and gastroesophageal reflux disease: current evidence and safety of dexlansoprazole

Gastroesophageal reflux disease is the most common upper gastroenterology disorder in the US. It is associated with a variety of complications and significantly impacts quality of life. Proton pump inhibitors are the most effective treatment. Dexlansoprazole modified release (MR) is a proton pump inhibitor that employs a novel release formulation that prolongs its absorption and allows for more flexibility in dosing. Dexlansoprazole MR can be dosed without regard to food intake or time of day, and once-daily dosing may replace twice-daily dosing of other agents. Dexlansoprazole MR is effective for healing and maintenance of erosive esophagitis, and for the treatment of nonerosive disease, including nocturnal gastroesophageal reflux disease. Dexlansoprazole MR is safe and well tolerated, and can improve quality of life.

EAES recommendations for the management of gastroesophageal reflux disease

BACKGROUND

Gastroesophageal reflux disease (GERD) is one of the most frequent benign disorders of the upper gastrointestinal tract. Management of GERD has always been controversial since modern medical therapy is very effective, but laparoscopic fundoplication is one of the few procedures that were quickly adapted to the minimal access technique. The purpose of this project was to analyze the current knowledge on GERD in regard to its pathophysiology, diagnostic assessment, medical therapy, and surgical therapy, and special circumstances such as GERD in children, Barrett's esophagus, and enteroesophageal and duodenogastroesophageal reflux.

METHODS

The European Association of Endoscopic Surgery (EAES) has tasked a group of experts, based on their clinical and scientific expertise in the field of GERD, to establish current guidelines in a consensus development conference. The expert panel was constituted in May 2012 and met in September 2012 and January 2013, followed by a Delphi process. Critical appraisal of the literature was accomplished. All articles were reviewed and classified according to the hierarchy of level of evidence and summarized in statements and recommendations, which were presented to the scientific community during the EAES yearly conference in a plenary session in Vienna 2013. A second Delphi process followed discussion in the plenary session.

RESULTS

Recommendations for pathophysiologic and epidemiologic considerations, symptom evaluation, diagnostic workup, medical therapy, and surgical therapy are presented. Diagnostic evaluation and adequate selection of patients are the most important features for success of the current management of GERD. Laparoscopic fundoplication is the most important therapeutic technique for the success of surgical therapy of GERD.

CONCLUSIONS

Since the background of GERD is multifactorial, the management of this disease requires a complex approach in diagnostic workup as well as for medical and surgical treatment. Laparoscopic fundoplication in well-selected patients is a successful therapeutic option.

Patient satisfaction with medication for gastroesophageal reflux disease: a systematic review

BACKGROUND

Patient satisfaction is increasingly regarded as an important aspect of measuring treatment success in individuals with gastroesophageal reflux disease (GERD).

OBJECTIVE

To review how satisfied patients with GERD are with their medication, and to analyze the usefulness of patient satisfaction as a clinical end point by comparing it with symptom improvement.

METHODS

Systematic searches of the PubMed and EMBASE databases identified clinical trials and patient surveys published between 1966 and 2009.

RESULTS

Twelve trials reported that 56% to 100% of patients were 'satisfied' or 'very satisfied' with proton pump inhibitor (PPI) treatment for GERD. Patient satisfaction levels were higher for PPIs than other GERD medications in two trials. The sample-size-weighted average proportion of patients 'satisfied' with their PPI after four weeks of treatment in trials was 93% (95% CI 87% to 99%), with 73% (95% CI 62% to 83%) being 'very satisfied'. In four surveys, the average proportion of patients 'satisfied' with their PPI treatment was 82% (95% CI 73% to 90%) and 62% (95% CI 48% to 75%) were 'very satisfied'. Seven trials found a positive association between patient satisfaction and symptom improvement, and two surveys between satisfaction and improved health-related quality of life. Three trials found that continuous treatment yielded higher rates of satisfaction than on-demand therapy.

CONCLUSIONS

More than one-half of patients were satisfied with their PPI medication in trials, and more patients were satisfied with PPIs than other medication types. An association between patient satisfaction and symptom resolution was found, suggesting that patient satisfaction is a useful end point for evaluating GERD treatment success.

Questionnaire based gastroesophageal reflux disease (GERD) assessment scales

Questionnaire based assessment scales for gastroesophageal reflux disease (GERD) have been utilized for assessment of the patient's symptomatology, assessment of symptom severity and frequency, assessment of health-related quality of life and for assessment of response to treatment. A multitude of unidimensional and multidimensional questionnaires exist for making symptom assessment and monitoring quality of life in GERD. Many of the scales meet some of the parameters of an ideal evaluative GERD specific assessment instrument. Yet, there are certain shortcomings and challenges which are faced in development of GERD questionnaires. This review discusses the features of an ideal symptom assessment instrument, examines the strengths and weaknesses of currently available questionnaires.

Prospective evaluation of quality of life in patients with Zollinger-Ellison syndrome

BACKGROUND

Zollinger-Ellison syndrome (ZES) is associated with complicated ulcer disease of the upper gastrointestinal tract. While management of ZES has dramatically improved with proton pump inhibitor therapy, quality of life in medically treated patients has not been evaluated.

METHODS

Over a 3-year period, 52 patients with ZES were prospectively evaluated at 6-month intervals with upper endoscopy and gastric acid analysis to evaluate the efficacy of current drug therapy and completion of SF36v2 forms. At each 6-month visit, patients' medication and problem lists were reviewed, comorbidities assessed, and any gastrointestinal symptoms recorded. Co-morbidity was represented as a simple illness count for the main analysis. The chronic disease score and the Charlson index were used for sensitivity analyses.

RESULTS

The unadjusted norm-based estimate of mental component score (MCS) for 52 patients with ZES (mean age 58, 65% male) was 49.8 (95% CI 46.4, 53.1). The unadjusted estimate of the physical component score (PCS) was 42.3 (95% CI 38.9, 45.7). As the number of illnesses or number of medications increased, there was a monotonic decrease in PCS scores. With multivariable adjustment, the coefficient for number of medications became non-significant. An increase in each of the co-morbidity indexes was associated with a decrease in PCS. Results did not vary by representation of co-morbidity. MCS was not significantly different from the general population.

CONCLUSIONS

Patients with medically managed ZES have norm-based estimates of the mental component scores as measured by the SF-36v2 that approximate normal values, while the physical component scores were decreased with this reduction largely explained by co-morbid illness.

Update on health-related quality of life in patients with gastroesophageal reflux disease

Gastroesophageal reflux disease is highly prevalent in westernized countries. It damages quality of life but its effect is frequently underestimated, often leading to inadequate management of the disease and its symptoms. Health-related quality of life questionnaires are now becoming more widely recognized as an effective means of demonstrating the true impact of gastroesophageal reflux disease, both on individuals and on society at large. Health-related quality of life questionnaires can also help to underscore the importance of effective acid suppression therapy, with proton pump inhibitors, such as omeprazole and esomeprazole, for this common and highly debilitating condition. This review summarizes recent information on the impact of gastroesophageal reflux disease on a range of aspects of health-related quality of life, including patient well-being.

[Health-related quality of life issues in gastroesophageal reflux disease]

Several studies have reported significant Health-Related Quality of life (HRQOL) impairment in gastroesophageal reflux disease (GERD) patients compared with the general population. The evaluation of quality of life is important as a parameter for the treatment. Because GERD has diverse symptoms such as esophageal and extraesophageal syndromes, HRQOL of GERD should be determined by both disease and non-disease related factors. The purpose is to overview the HRQOL instruments used in the evaluation of GERD, published reports regarding HRQOL in GERD, and the effects of medical treatments on GERD.

Long-term quality of life improvement in subjects with healed erosive esophagitis: treatment with lansoprazole

BACKGROUND

Gastroesophageal reflux disease (GERD) is a chronic symptomatic condition and may be associated with erosive esophagitis (EE). Considerable data on the long-term maintenance of healing of EE are available, but data on long-term GERD symptom prevention and patient quality of life (QOL) are limited.

AIMS

To investigate QOL in subjects with healed EE who received 12 months of double-blind maintenance treatment with lansoprazole or ranitidine, followed by long-term open-label lansoprazole therapy to prevent recurrence of EE.

METHODS

Subjects with healed EE received 12 months of double-blind maintenance treatment with lansoprazole 15 mg once daily or ranitidine 150 mg twice daily, followed by dose-titrated, open-label lansoprazole therapy for up to 82 months.

RESULTS

During double-blind treatment (n = 206), lansoprazole-treated patients showed significantly (P <or= 0.05) greater improvements than ranitidine-treated patients in the frequency, severity, and 'bothersomeness' of heartburn, the symptom index, problems of activity limitation, eating and drinking problems, symptom problems, health distress, and social functioning. During dose-titrated, open-label treatment (n = 195), all disease-specific QOL scales except sleep improved significantly (P < 0.001) from open-label baseline at each time-point.

CONCLUSIONS

Maintenance treatment with lansoprazole for 12 months in healed EE subjects produced significantly greater improvements in QOL indicators than ranitidine. These improvements were sustained during dose-titrated, open-label lansoprazole treatment.

Lansoprazole 15 mg once daily for 14 days is effective for treatment of frequent heartburn: results of 2 randomized, placebo-controlled, double-blind studies

OBJECTIVE

To investigate the efficacy and safety of a 14-day treatment period with lansoprazole 15 mg for frequent heartburn in patients who are likely to select a nonprescription medication before consulting a prescriber.

METHODS

Adults with untreated frequent heartburn > or = 2 days a week over the past month were recruited for 2 identical multicenter, double-blind studies conducted with a 1-week screening and heartburn medication washout, a 1-week placebo run-in, a 2-week placebo-controlled treatment, and a 1-week placebo follow-up. After the washout and placebo run-in, subjects were randomly assigned to receive lansoprazole 15 mg or placebo once daily for 14 days in a double-blind fashion. Antacid tablets were permitted as rescue medication. Endpoints included percentage of 24-hour days without heartburn (primary), percentage of night-times without heartburn, and percentage of subjects without heartburn during day 1 of treatment (secondary endpoints). Data were collected daily via an interactive voice response system.

RESULTS

In studies 1 and 2, 282 and 288 subjects, respectively, were randomly assigned to lansoprazole, and 282 in each study received placebo. The mean percentage of days without heartburn was greater among lansoprazole recipients compared with placebo recipients (P < 0.0001). Significantly more subjects treated with lansoprazole also reported no night-time heartburn and no heartburn during day 1 of the 14-day treatment. Adverse events were infrequent and were similar for lansoprazole and placebo groups.

CONCLUSION

During the 14-day treatment period in a population with frequent heartburn who were likely to select a medication without consulting a prescriber, lansoprazole 15 mg once daily showed rapid and sustained effectiveness throughout a 24-hour period and was well tolerated.

What makes individuals with gastroesophageal reflux disease dissatisfied with their treatment?

BACKGROUND & AIMS

Despite the efficacy of proton pump inhibitors (PPIs) as therapeutics for patients with gastroesophageal reflux disease (GERD) in randomized controlled trials, a number of studies have shown that a proportion of patients with GERD are not satisfied with their treatment. This article reviews the possible reasons why patients are dissatisfied with the way their disease is managed.

METHODS

Studies published between 1970 and 2007 were identified from PubMed, EMBASE, and the author's existing database. The 2708 publications were reviewed, and irrelevant ones were excluded. Eleven studies were found to be appropriate for use in this review.

RESULTS

Patients who are given prescriptions for PPIs tend to be more satisfied than those given H(2)-receptor antagonists. Partial responders are likely to be more dissatisfied than patients whose symptoms are fully resolved. A decrease in health-related quality of life is associated with greater dissatisfaction. Patients are more likely to be satisfied if they are taken seriously by their physician and if their symptoms are investigated. They are also more likely to be satisfied if the patient-physician consultation is interactive.

CONCLUSIONS

Patient satisfaction is a complex issue that depends on many factors. Patient satisfaction can be influenced by treatment regimen, general level of well-being, the bedside manner of the physician, and the quality of patient-physician communication. Improvements in recognition of GERD can improve management of the disease as well as patient satisfaction with their care and treatment.

Systematic review: health-related quality of life (HRQOL) questionnaires in gastro-oesophageal reflux disease

BACKGROUND

Although gastro-oesophageal reflux disease (GERD) has a well-established pathophysiology, the impact of GERD symptoms on the patients' quality of life can be profound. Therefore, health-related quality of life (HRQOL) questionnaires have become standard instruments to evaluate the effect of treatment in clinical trials.

AIM

To evaluate the reliability, validity and responsiveness of available GERD-specific HRQOL.

METHODS

A systematic literature search using the Medical Subject Headings terms: 'Gastro-oesophageal reflux', 'Heartburn' and 'Oesophagitis' with 'quality of life' and 'questionnaires' was preformed to identify the available HRQOL questionnaires. To analyse the psychometric properties of the respective tools, the actual guidelines for the use of patient-reported outcomes in clinical trials were applied.

RESULTS

We identified five GERD-specific HRQOL questionnaires but none of them fulfilled all quality criteria; either they did not meet the actual standards for psychometric properties (HBQOL, GERD-HRQL, Jasani et al.Aust Fam Physician 1999; 28: 515), or were impracticable to use in clinical trials. The generic and hybrid instruments lack specificity and sensitivity and were not designed for treatment evaluation in GERD patients.

CONCLUSION

There is need for a new evaluative tool in the assessment of HRQOL during GERD therapy.

Systematic review: the impact of gastro-oesophageal reflux disease on work productivity

BACKGROUND

Gastro-oesophageal reflux disease has wide-ranging effects on patients' lives.

AIM

To review systematically the effects of gastro-oesophageal reflux disease on work productivity.

METHODS

Studies of gastro-oesophageal reflux disease and work productivity were identified in a systematic literature search and their results were valued in US dollars using the human capital method. Work productivity loss was defined as absence from work (absenteeism) plus reduced effectiveness while working (presenteeism).

RESULTS

Eight eligible studies were included. Reported work productivity loss among individuals with gastro-oesophageal reflux disease ranged from 6% to 42% and was primarily because of presenteeism (6-40%) rather than absenteeism (<1% to 7%). Reported losses were greatest in patients experiencing sleep disturbance because of gastro-oesophageal reflux disease, and lowest in individuals from the general population taking appropriate prescription medication. Work productivity impairment correlated with symptom severity and responded to acid-suppressive therapy. Assuming a 40-h working week and average wages in the US, the weekly mean productivity loss per employee with gastro-oesophageal reflux disease can be estimated between 2.4 (62 dollars) and 16.6 h (430 dollars), depending on the population studied.

CONCLUSIONS

Gastro-oesophageal reflux disease has a substantial impact on employee productivity, primarily by impairing productivity while working. Further studies are needed to confirm that this impact can be decreased by acid-suppressive therapy.

Effect of esomeprazole on nighttime heartburn and sleep quality in patients with GERD: a randomized, placebo-controlled trial

OBJECTIVES

Sleep disturbances are common in patients with gastroesophageal reflux disease (GERD). This study examined the effects of esomeprazole on nighttime heartburn, GERD-related sleep disturbances, sleep quality, work productivity, and regular activities.

METHODS

This multicenter, randomized, double-blind, placebo-controlled trial included adults with GERD-associated sleep disturbances and moderate-to-severe nighttime heartburn (recorded by patient diary during screening). Patients received oral esomeprazole 40 mg (n = 220) or 20 mg (n = 226) or placebo (n = 229) once daily for 4 wk. The primary outcome was relief of nighttime heartburn. Secondary outcomes included resolution of sleep disturbances, sleep quality measured by the Pittsburgh Sleep Quality Index (PSQI) questionnaire, and work productivity measured by the Work Productivity and Activity Impairment Questionnaire.

RESULTS

Nighttime heartburn was relieved in 53.1% (111/209), 50.5% (111/220), and 12.7% (28/221) of patients who received esomeprazole 40 mg, esomeprazole 20 mg, and placebo, respectively. Differences (95% CI) versus placebo were 40.5% (32.4%, 48.5%) and 37.8% (29.9%, 45.7%) and were highly significant (p < 0.0001). GERD-related sleep disturbances resolved in significantly more (p < 0.0001) patients who received esomeprazole 40 (73.7%) or 20 mg (73.2%) than in those who received placebo (41.2%). Both esomeprazole groups had greater PSQI global score changes from baseline (p < 0.0001 vs placebo) and more (p < 0.0001 vs placebo) work hours saved per week per patient compared with baseline (esomeprazole 40 mg, 11.6 h; esomeprazole 20 mg, 12.3 h; placebo, 6.2 h).

CONCLUSIONS

Esomeprazole reduced nighttime heartburn and GERD-related sleep disturbances and improved sleep quality and work productivity.

Quality of Life Measurement in the Management of Gastroesophageal Reflux Disease

QOL measurement is being reported with increasing frequency in the surgical literature. The authors have found, as have others, that the use ofa generic instrument such as the SF36 in combination with a disease-specific instrument will provide the most comprehensive information. GERD isa significant health problem that primarily affects the QOL of a large segment of the population. New therapies for GERD continue to be developed and introduced into clinical practice. QOL assessment should bean important part of the evaluation of these new therapies.

Laparoscopic Nissen fundoplication in patients with nonerosive reflux disease. Long-term quality-of-life assessment and surgical outcome

BACKGROUND

It is known that laparoscopic antireflux surgery (LARS) can achieve an excellent surgical outcome including quality of life improvement in patients with erosive gastroesophageal reflux disease (GERD; EGD-positive). Less is known about the long-term surgical outcome in GERD patients who have no evidence of esophagitis (EGD-negative) before surgery. The aim of this study was to evaluate the surgical outcome in a well-selected group of EGD-negative patients compared to that of EGD-positive patients.

METHODS

From a large sample of more than 500 patients who underwent LARS, 89 EGD-negative patients (mean age, 51 +/- 6 years; 56 males) were treated surgically because of persistent reflux-related symptoms despite medical therapy. In all cases, preoperative 24-h pH monitoring showed pathological values. To perform a comparative analysis, a matched sample of EGD-positive patients (mean age, 54 +/- 10 years; 58 males) was selected from the database. Surgical outcome included for all patients objective data (e.g., manometry and pH data and endoscopy), quality of life evaluation [Gastrointestinal Quality of Life Index (GIQLI)] symptom evaluation, as well as patients' satisfaction with surgery. The data of a complete 5-year follow-up are available.

RESULTS

There were no significant differences in symptomatic improvement, percentage of persistent surgical side-effects, or objective parameters. In general, patients' satisfaction with surgery was comparable in both groups: 95% rated long-term outcome as excellent or good and would undergo surgical treatment again if necessary, respectively. Quality of life improvement was significantly better (p < 0.05) in the EGD-negative group because of the fact that GIQLI was more impaired before surgery (preoperative GIQLI, 81.7 +/- 11.6 points/EGD-negative vs 93.8 +/- 10.3 points/EGD-positive). Five years after surgery, GIQLI in both groups (121.2 +/- 8.5 for EGD-negative vs 120.9 +/- 7.3 for EGD-positive) showed comparable values to healthy controls (122.6 +/- 8.5).

CONCLUSION

We suggest that LARS is an excellent treatment option for well-selected patients with persistent GERD-related symptoms who have no endoscopic evidence of esophagitis.

Review article: impact of night-time reflux on lifestyle - unrecognized issues in reflux disease

Gastro-oesophageal reflux disease (GERD), manifesting with symptoms including heartburn and regurgitation, affects people during both daytime and nocturnal hours. Night-time GERD has been reported to have a greater impact on a patient's life than daytime GERD due to prolonged oesophageal acid exposure time per reflux episode. To further understand this issue, it is important to implement quality of life (QOL) measures. QOL studies are becoming increasingly important to physicians in making clinical decisions, and generic and disease-specific health-related QOL (HRQL) tools have been developed to measure a wide variety of topics. There are currently no universally accepted guidelines on how to best measure HRQL in GERD patients. It is important to note that these surveys may not yield accurate results because many GERD sufferers may feel that their symptoms are not serious enough to seek treatment. Some surveys include the GERD-HRQL assessment, the Short Form Health Survey (SF-36), and the Gallup survey. When compared with daytime GERD patients, night-time GERD patients may suffer from sleep deprivation, which in turn leads to physical and emotional problems and a poor overall QOL. Studies indicate that the prevalence and impact of night-time heartburn have been underestimated and that adequate treatment of symptoms is often not achieved. In addition, GERD greatly affects work productivity and leads to a significant economic burden on society. Although limited studies are available on the impact of pharmacological treatment on GERD QOL, recent findings indicate that proton pump inhibitors are more effective than H(2)-receptor antagonists for the improvement of overall QOL.

Sleep dysfunction in patients with gastro-oesophageal reflux disease: prevalence and response to GERD therapy, a pilot study

BACKGROUND

There is little information on the prevalence of pathological sleep disorders in patients with gastro-oesophageal reflux disease and whether pharmacological treatment of patients with gastro-oesophageal reflux disease will lead to improvement in sleep.

AIMS

This pilot study determined the prevalence of sleep disorder in patients with erosive gastro-oesophageal reflux disease, correlated subjective (questionnaire) and objective (actigraphy - a watch worn on the wrist that monitors motion to help differentiate sleep from awake states) assessment of sleep dysfunction and determined whether therapeutic resolution of oesophageal symptoms was associated with an improvement in sleep.

METHODS

Eighteen patients with erosive gastro-oesophageal reflux disease received esomeprazole 40 mg once daily for 8 weeks. Assessments at 0, 4 and 8 weeks included: Gastrointestinal Symptoms Rating Scale, Pittsburgh Sleep Quality Index questionnaire and ambulatory wrist actigraphy.

RESULTS

Unrecognized sleep disturbance occurred in 81% of this cohort of patients with gastro-oesophageal reflux disease and erosive oesophagitis. Median reflux syndrome score (heartburn and acid regurgitation) on Gastrointestinal Symptoms Rating Scale decreased from 2 at baseline to 0 at weeks 4 and 8 (P </= 0.0001). Median global Pittsburgh Sleep Quality Index score decreased from 8.50 at baseline to 4.50 at week 4 (P = 0.002) and to 7.00 at week 8 (P = 0.043). There were no significant changes in actigraphy measurements.

CONCLUSIONS

Sleep disturbance is common in patients with gastro-oesophageal reflux disease with erosive oesophagitis. This study which is the first to evaluate sleep abnormalities and gastro-oesophageal reflux disease using a validated questionnaire, demonstrates that in patients with gastro-oesophageal reflux disease, sleep improvement, may be effected by gastro-oesophageal reflux disease therapy. Actigraphy may be inappropriate for measurement of sleep disturbance in gastro-oesophageal reflux disease patients.

The role of acid suppression in patients with endoscopy-negative reflux disease: the effect of treatment with esomeprazole or omeprazole

BACKGROUND

Patients with endoscopy-negative reflux disease have reflux symptoms, mainly heartburn, but not mucosal breaks characteristic of erosive oesophagitis. Standard-dose proton pump inhibitors can provide symptom relief in endoscopy-negative reflux disease but the effect of greater acid suppression has not been studied.

AIM

To test the hypothesis that esomeprazole produces heartburn resolution in a greater proportion of patients with ENRD than omeprazole.

METHODS

Three multi-centre randomized, controlled, double-blind, 4-week acute treatment studies were conducted in endoscopy-negative reflux disease patients. In study A (n = 1282), patients received either esomeprazole 40 mg, esomeprazole 20 mg or omeprazole 20 mg daily; in studies B (n = 693) and C (n = 670) patients received either esomeprazole 40 mg or omeprazole 20 mg (B), and esomeprazole 20 mg or omeprazole 20 mg (C), respectively.

RESULTS

Resolution of heartburn at 4 weeks (no heartburn symptoms during the last 7 days) was achieved in similar proportions of patients in each treatment arm in study A (esomeprazole 40 mg, 56.7%; esomeprazole 20 mg, 60.5%; omeprazole 20 mg, 58.1%), study B (esomeprazole 40 mg, 70.3%; omeprazole 20 mg, 67.9%) and study C (esomeprazole 20 mg, 61.9%; omeprazole 20 mg, 59.6%). There were no significant differences between treatment groups within each study.

CONCLUSIONS

More than 60% of endoscopy-negative reflux disease patients reported heartburn resolution but, after 4 weeks of therapy, these proportions did not differ significantly between treatments.

Patient assessment of treatment satisfaction: methods and practical issues

Measurement of treatment satisfaction in gastro-oesophageal reflux disease (GORD) is compromised by an insufficient conceptual foundation and poor assessment methods. The current state of the art in measuring treatment satisfaction is incomplete, and the existing measurement is insufficient. Here, the definition, conceptualisation, application, and methodological issues associated with measurement of treatment satisfaction in GORD are reviewed. Treatment satisfaction may be important for differentiating among GORD treatments, and for monitoring patient outcomes in clinical practice.

Systematic review: do we need a new gastro-oesophageal reflux disease questionnaire?

BACKGROUND

Gastro-oesophageal reflux disease (GERD) is highly prevalent in Western countries. Because the majority of patients do not present with endoscopic abnormalities, the assessment of the symptom severity and quality of life, and their response to treatment, has become increasingly important. Self-assessed symptom questionnaires are now key instruments in clinical trials.

AIM

To evaluate the validity of available GERD measurement tools.

METHODS

An ideal GERD symptom assessment instrument, suitable as a primary end-point for clinical trials, should possess the following characteristics: (i) be sensitive in patients with GERD; (ii) cover the frequency and intensity of typical and atypical GERD symptoms; (iii) be multidimensional (cover all symptom dimensions); (iv) have proven psychometric properties (validity, reliability and responsiveness); (v) be practical and economical; (vi) be self-assessed; (vii) use 'word pictures' which are easy to understand for patients; (viii) respond rapidly to changes (responsiveness over short time intervals); (ix) be used daily to assess changes during and after therapy; and (x) be valid in different languages for international use.

RESULTS

A literature review revealed five scales that met some of the above characteristics, but did not fulfil all criteria.

CONCLUSION

There is a need for a new evaluative tool for the assessment of GERD symptoms and their response to therapy.

Development and validation of a disease-specific treatment satisfaction questionnaire for gastro-oesophageal reflux disease

BACKGROUND

Currently, no disease-specific, patient-based, treatment satisfaction instruments related to gastro-oesophageal reflux disease exist.

AIM

To develop and validate a treatment satisfaction questionnaire for gastro-oesophageal reflux disease (TSQ-G).

METHODS

A new questionnaire was developed from patient focus groups, clinician input and literature review. A validation study was conducted in treated gastro-oesophageal reflux disease patients. Ancillary measures included the Medical Outcomes Study Short Form-36, Quality of Life in Reflux and Dyspepsia, Gastrointestinal Symptom Rating Scale, Socially Desirable Response Scale, Patient Satisfaction Questionnaire-18 and physician and patient measures of symptoms and satisfaction. Statistical analyses included exploratory factor analysis, Cronbach's alpha, intra-class correlations, analyses of variance and t-tests.

RESULTS

A total of 198 gastro-oesophageal reflux disease patients participated in the study, with a mean age of 50.7 years, 68% female and 84% Caucasian. The physician-rated severity of gastro-oesophageal reflux disease was mild (32%), moderate (50%) and severe (18%); 83% were on proton pump inhibitors. The final TSQ-G consisted of 28 items with seven sub-scales; Cronbach's alpha ranged from 0.58 to 0.94. Correlations with the expected sub-scales of the ancillary measures were moderate to strong. The TSQ-G sub-scales discriminated significantly between levels of physician-rated disease severity, symptom days and patient and physician ratings of satisfaction.

CONCLUSIONS

The TSQ-G has excellent reliability and construct validity and appears to be a useful tool for the evaluation of treatment satisfaction in gastro-oesophageal reflux disease patients.

The impact of gastroesophageal reflux disease on quality of life

BACKGROUND

Quality of life as a medical endpoint has become an important measure in clinical research.

METHODS

In this article, we review the recent literature that has examined the impact of gastroesophageal reflux disease (GERD) and its treatment of quality of life.

RESULTS

The increasing interest in measuring patients' quality of life as an outcome reflects an increasing awareness that traditional physiological endpoints often do not correlate well with patients' functional status, general well-being, and satisfaction with therapy. It has been shown that GERD has a significant impact on patients' quality of life; therefore, improvement of quality of life is one of the major goals of GERD treatment. This can be achieved by medical as well as surgical treatment.

CONCLUSION

In addition to the patients' perspective, quality of life is one of the major endpoints in medical research that will help provide more selective treatment regimens for our patients.

The economic and quality-of-life impact of symptomatic gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is one of the most common complaints in general medical practice. Symptoms of GERD have a high prevalence, which greatly affects health economics and patient health-related quality of life (HRQOL). The majority of patients who present with reflux symptoms lack esophageal mucosal injury and thus have symptomatic GERD. There appear to be no differences in either symptoms or HRQOL measures between patients with or without positive endoscopy. Although most pharmacoeconomic and HRQOL assessments have focused on erosive GERD patients, available data suggest that the impact of symptomatic GERD on HRQOL is significant and equivalent to that associated with erosive disease. Proton pump inhibitors (PPIs) improve HRQOL to a greater extent than either histamine(2)-receptor antagonists or prokinetics in patients with GERD, with PPI-based step-down or "on-demand" strategies yielding the most cost-effective benefit to health. Additional HRQOL and outcomes research focused on patients with symptomatic GERD, ideally using disease-specific assessment tools, is needed. Furthermore, these management strategies must be implemented in real world settings to validate their effectiveness and firmly establish claims of reduced need for diagnostic testing and decreased direct medical costs.

Goals of therapy and guidelines for treatment success in symptomatic gastroesophageal reflux disease patients

Important new data have established symptomatic gastroesophageal reflux disease (GERD) as a disorder in its own right. Despite major advances in management, this disorder still presents many challenges. With the absence of visible disease (i.e., esophageal erosions), symptom relief must be a primary aim in treating patients with symptomatic GERD; in particular, reflux patients suffer from several different symptoms, but relief of heartburn and acid regurgitation should be the principal concern in clinical practice. Epigastric pain and other upper GI symptoms usually improve with active treatment. From a methodological standpoint, complete symptom relief is an attractive outcome measure. However, not all patients expect complete absence of symptoms in the long term, and many reflux patients are willing to continue a treatment strategy that provides substantial but less than absolute symptom control. Patients with symptomatic GERD have significantly impaired health-related quality of life (HRQOL) which, when heartburn is resolved, often improves to levels equal to or better than that found in the normal, healthy population. However, some reflux sufferers may not report symptoms and have apparently normal HRQOL measures owing only to the fact that they self-impose rigorous lifestyle restrictions to prevent heartburn-restrictions that may, in turn, eventually lead to HRQOL impairment. A full and complete evaluation of treatment success should be able to detect this pattern. Data on the long-term prognosis and risk of complications associated with treatment for symptomatic GERD are scarce and incomplete. However, the prevention of erosive esophageal damage, strictures, and adenocarcinoma should be a goal of long-term treatment success, even in symptomatic GERD.