Prognostic factors for relapse and maintenance treatment with cisapride in gastro-oesophageal reflux disease

A glass of water immediately increases gastric pH in healthy subjects

Onset of action of antisecretory agents is of pivotal importance for patients with gastroesophageal reflux disease (GERD) treated "on-demand."

AIM

To study the acute effect of acid-inhibiting drugs and water administration on gastric pH.

METHOD

A cross-over study was performed in 12 H. pylori (-), healthy subjects (6 men; mean age: 26 years). A single oral dose of the following agents was received with a wash-out period between each study: a glass of water (200 ml), antacid, ranitidine, omeprazole, esomeprazole, and rabeprazole. Gastric pH was recorded for 6 h after drug intake.

RESULTS

Water increased gastric pH >4 in 10/12 subjects after 1 min. The time (median) needed to pH >4 was for: antacid 2 min, ranitidine 50 min, omeprazole 171 min, esomeprazole 151 min, and rabeprazole 175 min. Gastric pH >4 lasted for 3 min after water and for 12 min after antacids; it remained >4 until the end of recording in: 4/12 subjects with ranitidine, 11/12 with rabeprazole, and all with omeprazole and esomeprazole.

CONCLUSION

Water and antacid immediately increased gastric pH, while PPIs showed a delayed but prolonged effect compared to ranitidine.

Efficacy of pantoprazole 20 mg daily compared with esomeprazole 20 mg daily in the maintenance of healed gastroesophageal reflux disease: a randomized, double-blind comparative trial - the EMANCIPATE study

OBJECTIVES

To compare the efficacy and tolerability of pantoprazole 20 mg once daily with that of esomeprazole 20 mg once daily for 6 months as maintenance therapy in patients with previously healed gastroesophageal reflux disease.

METHODS

In an initial open-label acute phase, outpatients with endoscopically confirmed gastroesophageal reflux disease (Los Angeles grades A-D) received pantoprazole 40 mg once daily for 4 or 8 weeks. Those healed (defined as the absence of esophagitis, and 'no' or 'mild' heartburn and acid regurgitation) were randomized in the double-blind manner for maintenance therapy with pantoprazole 20 mg once daily or esomeprazole 20 mg once daily for 6 months.

RESULTS

In the acute healing phase, 1452 patients were recruited to receive pantoprazole 40 mg once daily. Healing success was 91% (intent-to-treat analysis). A total of 1303 patients entered the maintenance phase of the study. Pantoprazole 20 mg once daily and esomeprazole 20 mg once daily were equally effective at maintaining patients in remission; 84 and 85% of pantoprazole and esomeprazole recipients remained in combined endoscopic and symptomatic remission at 6 months (intent-to-treat analysis). The confidence interval of the difference was (-5.7; +infinity), showing that pantoprazole is as effective as esomeprazole with a noninferiority margin of 5.8%. Combined endoscopic and symptomatic remission was independent of Helicobacter pylori status. Both treatments were well tolerated and safe.

CONCLUSION

Treatment with pantoprazole 20 mg once daily or esomeprazole 20 mg once daily provides similarly effective and well-tolerated maintenance of previously healed gastroesophageal reflux disease irrespective of baseline H. pylori status.

Efficacy of esomeprazole in patients with acid-peptic disorders

Esomeprazole (Nexium) is a new proton pump inhibitor that provides more effective acid control compared with other proton pump inhibitors. In patients with gastroesophageal reflux disease, standard doses of esomeprazole maintain intragastric pH above 4 for significantly longer periods compared with standard doses of other proton pump inhibitors after 5 days of treatment. Esomeprazole is approved for the treatment of symptomatic gastroesophageal reflux disease, the healing of erosive esophagitis, and maintenance of healing. In clinical trials, esomeprazole 40 mg once daily for up to 8 weeks provided higher rates of healing of erosive esophagitis and a greater proportion of patients with sustained resolution of heartburn, than either omeprazole 20 mg or lansoprazole 30 mg once daily. For the maintenance of healing, esomeprazole 20 mg once daily provided significantly higher rates of maintained healing of erosive esophagitis after 6 months of treatment compared with lansoprazole 15 mg once daily. Esomeprazole is also approved for use as part of a triple-drug therapy regimen in combination with amoxicillin and clarithromycin for the eradication of Helicobacter pylori in patients with duodenal ulcer disease. The side effect profile of esomeprazole is similar to that of omeprazole. Many patients with acid-related disorders may benefit from the more rapid symptom relief, higher rates of healing of erosive esophagitis, and improved maintenance of healing that can be achieved with esomeprazole.

Review article: treatment of mild and severe cases of GERD

GERD prevalence continues to rise in contrast to peptic ulcer disease. The spectrum contains reflux esophagitis and so-called 'endoscopy-negative GERD' or 'non-erosive GERD' (NERD) or S-GERD and patients with 'normal' overall 24-h esophageal acidification but with a high 'symptom-index'. The majority of reflux patients will not need endoscopy initially. Prompt referral for endoscopy is indicated only if the patient has atypical symptoms or alarm symptoms such as dysphagia, anemia, weight loss, severe abdominal pain, or pain that does not respond to acid neutralization or suppression, or develops symptoms after the age of 50 years. Antireflux therapy consist of raising the head of the bed, maintaining normal weight, and avoidance of foods and drugs that precipitate symptoms, together with antacids or over-the-counter H(2) receptor antagonists (H(2)RAs). If symptoms persist after these simple measures or if antacids or H(2)RAs are needed quite often, then a more formal first-line treatment should be started. Many experts feel that a stepdown approach instead of a stepup approach is clinically and economically a more appropriate way of installing such first-line therapy. Physicians increasingly consider prescribing a (low- or standard dose) once-a-day proton pump inhibitor (PPI) as firstline therapy. If symptoms recur after 4-week trial or are in sufficiently relieved, then the patient should be referred for endoscopy. Endoscopy may reveal no abnormalities (NERD) or evidence of reflux-induced damage. Treatment of endoscopy-negative reflux disease should be directed towards rapid relief of symptoms and then maintenance of relief using minimum effective therapy. Responses to PPIs are somewhat lower in endoscopy-negative patients compared to esophagitis. Some form of long-term therapy is needed in the majority of patients. 'On demand' PPI therapy to control reflux symptoms is a new and attractive option. The goal of treatment of GERD should be to relieve symptoms and to heal lesions. Symptom severity and much less endoscopic abnormalities, drives the therapy. When symptoms are mild or intermittent and when esophagitis is absent or minimal, standard dose PPI is usually reinstituted. If there is moderate or severe esophagitis or if symptoms are particularly troublesome, then the patient should start again with standard-dose PPI therapy once a day, but not uncommonly a b.i.d. dosage maybe necessary. Once a dose of the acid suppressant that relieves symptoms is found, this dose should be maintained for a period of 3 months. After this time, an attempt should be made to reduce the dose. A plan should be formulated for long-term treatment.

Review article: long-term use of proton pump inhibitors in GORD--help or hindrance?

Many patients with gastro-oesophageal reflux disease (GORD) experience chronic relapses and require maintenance therapy for symptomatic relief. This article reviews possible mechanisms for chronic relapse in GORD, and discusses the risks and benefits of proton pump inhibitors as maintenance therapy for this disease. Recent medical literature was reviewed to gather information about proton pump inhibitor therapy and GORD. The reports indicated that the tendency to relapse in GORD is probably related to ongoing motor defects and to the acid rebound that follows successful healing therapy. Proton pump inhibitors are very effective in maintaining symptomatic and endoscopic remission in GORD. Limitations of proton pump inhibitor therapy have largely so far been clinically irrelevant. Most side-effects are inherent consequences of any form of acid suppression therapy, and include hypergastrinaemia and rebound hyperacidity upon discontinuation of therapy. We conclude that the therapeutic balance tips toward proton pump inhibitors for treatment of GORD because their limitations are largely surpassed by excellent clinical efficacy, tolerance, and lack of serious adverse effects.

The new proton pump inhibitor esomeprazole is effective as a maintenance therapy in GERD patients with healed erosive oesophagitis: a 6-month, randomized, double-blind, placebo-controlled study of efficacy and safety

BACKGROUND

Esomeprazole, the S-isomer of omeprazole, is the first proton pump inhibitor to be developed as an optical isomer. In patients with erosive oesophagitis, esomeprazole has produced significantly greater healing rates and improved symptom resolution vs. omeprazole.

AIM

This study assesses the efficacy of esomeprazole for preventing relapse in patients with healed oesophagitis.

METHODS

In this 6-month US multicentre randomized double-blind placebo-controlled trial, 375 Helicobacter pylori-negative patients with endoscopically healed oesophagitis received esomeprazole 40 mg, 20 mg, 10 mg, or placebo once daily. The primary efficacy end-point was maintenance of healing at 6 months. Secondary end-points assessed changes in symptoms, and long-term safety and tolerability.

RESULTS

Significantly (P < 0.001) more patients remained healed with esomeprazole 40 mg (87.9%), 20 mg (78.7%), or 10 mg (54.2%), than with placebo (29.1%). Relapse, when it occurred, was later with esomeprazole. Sustained resolution of heartburn was observed in the 40 mg and 20 mg groups; there was a high correlation between absence of heartburn and maintenance of healing. Adverse effects were mild, infrequent and not significantly different between groups.

CONCLUSIONS

Esomeprazole is effective and well-tolerated in the maintenance of healing of erosive oesophagitis. Esomeprazole 40 mg and 20 mg offer significant clinical benefit to patients.

Symptomatic gastro-oesophageal reflux disease: double blind controlled study of intermittent treatment with omeprazole or ranitidine. The European Study Group

OBJECTIVE

To assess intermittent treatment over 12 months in patients with symptomatic gastro-oesophageal reflux disease.

DESIGN

Randomised, multicentre, double blind, controlled study. Patients with heartburn and normal endoscopy results or mild erosive changes received omeprazole 10 mg or 20 mg daily or ranitidine 150 mg twice daily for 2 weeks. Patients remaining symptomatic had omeprazole 10 mg or ranitidine dose doubled for another 2 weeks while omeprazole 20 mg was continued for 2 weeks. Patients who were symptomatic or mildly symptomatic were followed up for 12 months. Recurrences of moderate or severe heartburn during follow up were treated with the dose which was successful for initial symptom control.

SETTING

Hospitals and primary care practices between 1994 and 1996.

SUBJECTS

677 patients with gastro-oesophageal reflux disease.

MAIN OUTCOME MEASURES

Total time off active treatment, time to failure of intermittent treatment, and outcomes ranked from best to worst.

RESULTS

704 patients were randomised, 677 were eligible for analyses; 318 reached the end of the study with intermittent treatment without recourse to maintenance antisecretory drugs. The median number of days off active treatment during follow up was 142 for the entire study (281 for the 526 patients who reached a treatment related end point). Thus, about half the patients did not require treatment for at least 6 months, and this was similar in all three treatment groups. According to outcome, 378 (72%) patients were in the best outcome ranks (no relapse or one (or more) relapse but in remission until 12 months); 630 (93%) had three or fewer relapses in the intermittent treatment phase. Omeprazole 20 mg provided faster relief of heartburn. The results were similar in patients with erosive and non-erosive disease.

CONCLUSIONS

Intermittent treatment is effective in managing symptoms of heartburn in half of patients with uncomplicated gastro-oesophageal reflux disease. It is simple and applicable in general practice, where most patients are seen.

Functional gut disorders: from motility to sensitivity disorders. A review of current and investigational drugs for their management

Functional gut disorders include several clinical entities defined on the basis of symptom patterns (e.g., functional dyspepsia, irritable bowel syndrome, functional abdominal pain, functional abdominal bloating), for which there is no established pathophysiological mechanism. Because there is no well-defined pathophysiological target, treatment should be aimed at symptom improvement. Prokinetics and antispasmodics have been widely used in the treatment of functional gut disorders on the assumption that disordered motility is the underlying cause of symptoms, and symptom improvement is indeed achievable with these compounds in some, but not all, patients with features of hypo- or hypermotility, respectively. In the first part of this review, we cover the basic pharmacology and discuss the rationale for the clinical use of prokinetics and antispasmodics. On the other hand, in the past few years, the explosive growth in the research focusing on visceral sensitivity and visceral reflexes has suggested that at least some patients with functional gut disorders have altered visceral perception. Thus, the second part of the review covers these developments and focuses on studies addressing the issue of drugs modulating visceral sensitivity.

The effect of cisapride in maintaining symptomatic remission in patients with gastro-oesophageal reflux disease

BACKGROUND

Successful treatment of gastro-oesophageal reflux disease (GORD) has traditionally been assessed as healing of reflux oesophagitis, which may not be relevant in patients with moderate disease. In these patients symptom relief and patient satisfaction with therapy are of fundamental importance. Cisapride has well-documented prokinetic effects and may be well suited for long-term therapy of GORD, but its effectiveness in purely symptomatic treatment is unknown. We therefore compared two dosage regimens of cisapride with placebo over a period of 6 months in patients with evidence of gastrooesophageal reflux, initially treated with antisecretory medication, with regard to maintaining symptom relief and satisfaction with treatment.

METHODS

Five hundred and thirty-five patients with reflux oesophagitis grade 1 (n = 293) or 2 (n = 124) or with no reflux oesophagitis but pathologic 24-h pH-metry (n = 118) achieved satisfactory symptom relief with an H2-receptor antagonist or proton pump inhibitor within 4-8 weeks. In a double-blind randomized, parallel-group study, they were then treated with cisapride, 20 mg at night or 20 mg twice daily, or placebo and followed up for a maximum period of 6 months. Relapse was defined as dissatisfaction with therapy or an average consumption of more than two antacid tablets a day.

RESULTS

Median time to relapse was 63 days for cisapride, 20 mg twice daily; 59 days for cisapride, 20 mg at night; and 49 days for placebo. Time to relapse was not significantly different (P = 0.09). Presence and grade of oesophagitis at base line, type of therapy before randomization, and pattern of non-reflux symptoms at base line did not influence these findings significantly.

CONCLUSION

The study indicates that cisapride is of limited value in maintenance therapy of GORD in patients in whom symptom relief has been accomplished with potent antisecretory medication. This 'step-down' approach to therapy seems disadvantageous in the long-term therapy of GORD.