Costs and efficacy of three different esomeprazole treatment strategies for long-term management of gastro-oesophageal reflux symptoms in primary care

Evidence-based clinical practice guidelines for gastroesophageal reflux disease 2021

In Japan, with the increasing prevalence of gastroesophageal reflux disease (GERD) and growing public interest, the Japanese Society of Gastroenterology issued Evidence-based Clinical Practice Guidelines for GERD (1st edition) in 2009 and a revised 2nd edition in 2015. A number of studies on GERD were subsequently conducted in Japan and abroad, and vonoprazan, a potassium-competitive acid blocker (P-CAB), became available for the first time in Japan in February 2015. The revised 3rd edition (Japanese edition), which incorporates new findings and information, was published in April 2021. These guidelines are summarized herein, particularly sections related to the treatment of GERD. The important clinical issues addressed in the present revision are (i) the introduction of treatment algorithms that classify GERD into reflux esophagitis and non-erosive reflux disease, (ii) the clarification of treatment algorithms based on to the severity of reflux esophagitis, and (iii) the positioning of vonoprazan in the treatment for GERD. The present guidelines propose vonoprazan as the initial/maintenance treatment for severe reflux esophagitis. They also recommend vonoprazan or PPI as an initial treatment for mild reflux esophagitis and recommended PPI and proposed vonoprazan as maintenance treatment. These updated guidelines offer the best clinical strategies for GERD patients in Japan and hope that they will be of global use for the diagnosis and treatment for GERD.

Treatment strategies for reflux esophagitis including a potassium-competitive acid blocker: A cost-effectiveness analysis in Japan

INTRODUCTION

Gastroesophageal reflux disease is a common condition, and proton pump inhibitors (PPIs) are the mainstays of treatment. However, concerns have been raised about the safety of PPIs. A potassium-competitive acid blocker (P-CAB), vonoprazan (VPZ), was recently introduced, which may provide clinical benefits. This study was performed to investigate the cost-effectiveness of alternative long-term strategies including continuous and discontinuous treatment with VPZ for the management of reflux esophagitis in Japan.

METHODS

A health state transition model was developed to capture the long-term management of reflux esophagitis. Four different strategies were compared: (a) intermittent PPI using lansoprazole (LPZ); (b) intermittent P-CAB; (c) maintenance PPI using LPZ; and (d) maintenance P-CAB.

RESULTS

Intermittent P-CAB was the most cost-effective, and the number of days for which medication was required with this strategy was fewest. Maintenance PPI was more efficacious, but more costly than intermittent P-CAB. Maintenance P-CAB was more efficacious, but more costly than maintenance PPI. Co-payments were higher for maintenance PPI than for intermittent P-CAB, and for maintenance P-CAB than for maintenance PPI, which were considered reasonable for the majority of patients to improve symptoms.

CONCLUSIONS

Intermittent P-CAB appears to be the strategy of choice for the majority of reflux esophagitis patients in clinical practice. If a patient is not satisfied with the symptom control of the current strategy, switching to a more effective strategy appears to be a reasonable option for the majority of patients.

Comparison of Characteristics According to Reflux Type in Patients With Laryngopharyngeal Reflux

OBJECTIVES

To analyze laryngopharyngeal reflux (LPR) as an acidic, nonacidic, or mixed type according to 24-hour multi-channel intraluminal impedance (MII) pH monitoring and the clinical characteristics of each type.

METHODS

Ninety patients were prospectively enrolled in this study. All patients underwent 24-hour MII pH monitoring as a diagnostic tool. Eighty-three patients were diagnosed with LPR. The patients were classified into three groups according to the pH of the hypopharyngeal probe: the acid reflux group, nonacid reflux group, and mixed reflux group. Subjective symptoms and objective findings were evaluated based on patients' responses to the Short Form 12 Survey (SF-12), LPR health-related quality of life (LPR-HRQOL), reflux symptom index, and reflux finding score.

RESULTS

The results of each group were compared. As a result, 34 patients were classified into the nonacid reflux group and 49 into the mixed reflux group. There were no patients classified as having acid reflux alone. There was no significant difference between the two groups when comparing the reflux symptom index, reflux finding score, LPR-HRQOL, or the mental component score of the SF-12. However, the physical component score of the SF-12 was higher in the nonacid reflux group (P=0.018). The DeMeester composite score (P=0.015) and total number of LPR events (P=0.001) were lower in the nonacid reflux group than in the mixed reflux group.

CONCLUSION

In conclusion, no LPR patient had only acid reflux. The nonacid reflux LPR patients showed similar clinical characteristics and findings compared to the mixed reflux group, but exhibited significantly fewer LPR episodes.

Evidence-based clinical practice guidelines for gastroesophageal reflux disease 2015

As an increase in gastroesophageal reflux disease (GERD) has been reported in Japan, and public interest in GERD has been increasing, the Japanese Society of Gastroenterology published the Evidence-based Clinical Practice Guidelines for GERD (1st edition) in 2009. Six years have passed since its publication, and there have been a large number of reports in Japan concerning the epidemiology, pathophysiology, treatment, and Barrett's esophagus during this period. By incorporating the contents of these reports, the guidelines were completely revised, and a new edition was published in October 2015. The revised edition consists of eight items: epidemiology, pathophysiology, diagnosis, internal treatment, surgical treatment, esophagitis after surgery of the upper gastrointestinal tract, extraesophageal symptoms, and Barrett's esophagus. This paper summarizes these guidelines, particularly the parts related to the treatment for GERD. In the present revision, aggressive proton pump inhibitor (PPI) maintenance therapy is recommended for severe erosive GERD, and on-demand therapy or continuous maintenance therapy is recommended for mild erosive GERD or PPI-responsive non-erosive GERD. Moreover, PPI-resistant GERD (insufficient symptomatic improvement and/or esophageal mucosal break persisting despite the administration of PPI at a standard dose for 8 weeks) is defined, and a standard-dose PPI twice a day, change in PPI, change in the PPI timing of dosing, addition of a prokinetic drug, addition of rikkunshito (traditional Japanese herbal medicine), and addition of histamine H2-receptor antagonist are recommended for its treatment. If no improvement is observed even after these treatments, pathophysiological evaluation with esophageal impedance-pH monitoring or esophageal manometry at an expert facility for diseases of the esophagus is recommended.

Clinical drug trials in general practice: a 10-year overview of protocols

Background

Drugs predominantly prescribed in general practice should ideally be tested in that setting; however, little is known about drug trials in general practice. Our aim was to describe drug trials in Norwegian general practice over the period of a decade.

Methods

The present work concerns a 10-year retrospective study of protocols submitted to the Norwegian national medicines agency (1998 to 2007) identifying all studies involving general practitioners (GPs) as clinical investigator(s). We analyzed the number of trials, drug company involvement, patients, participating doctors, payment, medications tested and main diagnostic criteria for inclusion. We also analyzed one trial in greater detail.

Results

Out of 2,054 clinical drug trials, 196 (9.5%) were undertaken in general practice; 93% were multinational, 96% were industry funded and 77% included patients both from general practice and specialist care. The trials were planned to be completed in the period 1998 to 2012. A total of 23,000 patients in Norway and 340,000 patients internationally were planned to be included in the 196 trials. A median of 5 GPs participated in each trial (range 1 to 402). Only 0.7% of 831 GP investigators had general practice university affiliations. Median payment for participating investigators was €1,900 (range €0 to 13,500) per patient completing the trial. A total of 30 pharmaceutical companies were involved. The drugs most commonly studied were antidiabetics (21%), obstructive airway disease medications (12%), agents acting on the renin-angiotensin system (10%), and lipid modifying agents (10%). One trial, presented in more detail, had several characteristics of a seeding or marketing trial.

Conclusions

Only one in four drug trials involving general practice were solely general practice trials and almost all were industry initiated without input from academic general practice. There was a large variation in the number of patients, participating doctors, and economic compensation for trial investigators, with some investigators receiving substantial payments.

[The Mexican consensus on gastroesophageal reflux disease. Part I]

BACKGROUND

The changes, advances, and new discoveries regarding different aspects of gastroesophageal reflux disease (GERD) have made it necessary to update the Mexican Consensus published in 2002.

AIMS

To elaborate a new Mexican Consensus on GERD.

METHODS

The general project coordinators selected six GERD experts to carry out an extensive review of the literature for the purpose of elaborating statements on the principal aspects of GERD. These were then placed under the consideration of specialists in the study of this disease. Definitive approval by all participants was reached using the modified Delphi method with three rounds of anonymous and iterative voting. The following scale was employed: A- in complete agreement; B- in agreement, but with minor concerns; C- in agreement, but with major concerns; D- in disagreement, but with major concerns; E- in disagreement, but with minor concerns; or F- in complete disagreement. Consensus was declared when 67.00% or more of the participants concurred on a category of agreement (A, B, or C).

RESULTS

A consensus was reached on 160 of the statements upon completion of the voting rounds, with 90.00% concurrence for the majority of them.

CONCLUSIONS

The 2011 Mexican Consensus on Gastroesophageal Disease is a practical and up-to-date consultation tool, providing the opinion of Mexican experts on all the new information available about this disease. It allows there to be homogeneity in diagnostic and therapeutic criteria, all of which serves to benefit our patients.

Does participation in clinical trials influence the costs of future management of patients?

BACKGROUND

An earlier study showed that from a societal perspective it was less expensive to encourage patients to self-regulate their medication for GERD (gastro-esophageal reflux disease) by treating patients on-demand.

OBJECTIVE

The objective was to investigate whether physician involvement in a clinical trial financed by the pharmaceutical industry subsequently results in higher health care costs.

STUDY DESIGN

An open, observational, multicenter study compared direct medical costs and total costs for three groups of patients with different exposure to the clinical trial; (1) Dual exposed, where both the patients and the GP participated in the former clinical trial, (2) GP exposed, where only the GP participated in the former clinical trial and (3) nonexposed, where neither the patients nor the GP participated in the former clinical trial.

RESULTS

We did not find any statistically significant differences in neither direct medical nor total costs. However, we did observe a numerical difference in direct medical costs of 24% higher in the dual exposed group compared to the nonexposed group mainly due to a higher consumption of prescribed medication. The higher direct medical cost in the dual exposed group was however counterbalanced by lower observed direct nonmedical and indirect costs.

CONCLUSION

Although we did not find any statistical significant differences in health care costs, we did observe a higher consumption of prescribed medication and lower costs of work hours lost if both patient and GPs participated in a former clinical trial. The results may be limited due to a lower number of patients included than expected.

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.

Lifestyle factors affecting gastroesophageal reflux disease symptoms: a cross-sectional study of healthy 19864 adults using FSSG scores

BACKGROUND

Gastroesophageal reflux disease (GERD) is a very common disorder worldwide, comprised of reflux esophagitis (RE) and non-erosive reflux disease (NERD). As more than half of GERD patients are classified into the NERD group, precise evaluation of bothersome epigastric symptoms is essential. Nevertheless, compared with many reports targeting endoscopic reflux esophagitis, large-scale studies focusing on GERD symptoms have been very scarce.

METHODS

To elucidate lifestyle factors affecting GERD symptoms, 19,864 healthy adults in Japan were analyzed. Sub-analyses of 371 proton pump inhibitor (PPI) users and 539 histamine H₂-receptor antagonist (H₂RA) users were also performed. Using the FSSG (Frequency Scale for the Symptoms of GERD) score as a response variable, 25 lifestyle-related factors were univariately evaluated by Student's t-test or Pearson's correlation coefficient, and were further analyzed with multiple linear regression modelling.

RESULTS

Average FSSG scores were 4.8 ± 5.2 for total subjects, 9.0 ± 7.3 for PPI users, and 8.2 ± 6.6 for H₂RA users. Among the total population, positively correlated factors and standardized coefficients (β) for FSSG scores are inadequate sleep (β = 0.158), digestive drug users (β = 0.0972 for PPI, β = 0.0903 for H₂RA, and β = 0.104 for others), increased body weight in adulthood (β = 0.081), dinner just before bedtime (β = 0.061), the habit of midnight snack (β = 0.055), lower body mass index (β = 0.054), NSAID users (β = 0.051), female gender (β = 0.048), lack of breakfast (β = 0.045), lack of physical exercise (β = 0.035), younger age (β = 0.033), antihyperglycemic agents non-users (β = 0.026), the habit of quick eating (β = 0.025), alcohol drinking (β = 0.025), history of gastrectomy (β = 0.024), history of cardiovascular disease (β = 0.020), and smoking (β = 0.018). Positively correlated factors for PPI users are female gender (β = 0.198), inadequate sleep (β = 0.150), lack of breakfast (β = 0.146), antihypertensive agent non-users (β = 0.134), and dinner just before bedtime (β = 0.129), whereas those for H₂RA users are inadequate sleep (β = 0.248), habit of midnight snack (β = 0.160), anticoagulants non-users (β = 0.106), and antihypertensive agents non-users (β = 0.095).

CONCLUSIONS

Among many lifestyle-related factors correlated with GERD symptoms, poor quality of sleep and irregular dietary habits are strong risk factors for high FSSG scores. At present, usual dose of PPI or H₂RA in Japan cannot fully relieve GERD symptoms.

The effects of a novel metabotropic glutamate receptor 5 antagonist (AZD2066) on transient lower oesophageal sphincter relaxations and reflux episodes in healthy volunteers

BACKGROUND

Selective metabotropic glutamate receptor 5 (mGluR5) antagonists inhibit transient lower oesophageal sphincter relaxations (TLESRs) in animals and acid reflux in humans.

AIM

To assess the effect of single doses of the mGluR5 antagonist AZD2066 on TLESRs and reflux in humans.

METHODS

Healthy male volunteers received AZD2066 13 mg and placebo (part A), or AZD2066 2 mg and AZD2066 6 mg and placebo (part B), in a randomised crossover study. Postprandial manometry/pH-impedance measurements were taken after each dose.

RESULTS

A total of 13 individuals completed part A of the study and 19 individuals completed part B. There was a significant reduction in the geometric mean number of TLESRs (27%; P = 0.02) and the geometric mean number of reflux episodes (51%; P = 0.01) in subjects receiving AZD2066 13 mg compared with placebo. Adverse events in participants receiving AZD2066 13 mg were mostly related to the nervous system [dizziness (3/13); disturbance in attention (3/13)]. Adverse events were reversible and of mild intensity. There were no serious adverse events. The effects of AZD2066 appeared dose-dependent, with smaller reductions in TLESRs and reflux episodes (relative to placebo) and fewer adverse events observed for AZD2066 2 mg and AZD2066 6 mg compared with AZD2066 13 mg.

CONCLUSION

The mGluR5-mediated inhibition of TLESRs may be a useful approach for inhibiting gastro-oesophageal reflux.

Esomeprazole relieves upper gastrointestinal symptoms in high-risk and average-risk NSAID users in daily clinical practice: results from an open-label study

OBJECTIVE

To investigate whether esomeprazole can provide relief for nonsteroidal anti-inflammatory drug (NSAID)-associated upper gastrointestinal symptoms in patients at different gastrointestinal risk.

METHODS

A multicentre, prospective, open-label study was conducted, wherein NSAID users visiting their general practitioner for upper gastrointestinal symptoms were asked to participate. Patients were treated with 20 mg esomeprazole and treatment effect was evaluated within 8 weeks. Response was defined as a maximum of 1 day per week with gastrointestinal symptoms during the last week of treatment. Partial response was defined as more than 50% improvement in the number of days per week with symptoms compared with baseline. Patients not meeting the above-mentioned criteria were classified as nonresponders. Patients who completely responded were compared with partial responders and nonresponders and were analysed according to their baseline gastrointestinal risk.

RESULTS

A total of 1042 patients (mean age: 57 years; standard deviation: 15; 43% male) were analysed. Complete response, partial response and nonresponse were achieved in 57, 24 and 19% of the patients, respectively. Similar response was seen in average-risk and high-risk patients (58 and 56%; P=0.46) and in nonselective NSAID and selective cyclooxygenase-2 users (57 and 53%; P=0.32).

CONCLUSION

Esomeprazole (20  mg) improved NSAID-associated upper gastrointestinal symptoms. Baseline gastrointestinal risk did not influence esomeprazole effectiveness.

What is nonacid reflux disease?

Proton pump inhibitors (PPIs) are the gold standard treatment for gastroesophageal reflux disease. In clinical practice, failure of PPIs occurs frequently, and may affect up to 30% of patients in a typical gastroenterology practice. Multichannel impedance monitoring combined with pH monitoring helps to detect nonacid reflux, and if symptoms correlate with these nonacid reflux episodes, nonacid reflux disease can be diagnosed. In contrast to PPIs, reflux inhibitors target transient lower esophageal sphincter relaxations, which are involved in the pathophysiology of reflux disease and may be the appropriate future treatment for nonacid reflux disease. The present article discusses the current understanding of nonacid reflux disease, its diagnosis and treatment.

Systematic review: persistent reflux symptoms on proton pump inhibitor therapy in primary care and community studies

BACKGROUND

Persistent gastro-oesophageal reflux disease (GERD) symptoms can occur despite proton pump inhibitor (PPI) therapy.

AIM

To assess the prevalence and potential determinants of persistent GERD symptoms in primary care and community-based studies.

METHODS

Studies were identified by systematic PubMed and Embase searches; pooled prevalence data are shown as sample-size weighted means and 95% confidence intervals.

RESULTS

Nineteen studies in individuals with GERD taking a PPI were included. In interventional, nonrandomized primary care trials, the prevalence of persistent troublesome heartburn and regurgitation was 17% (6-28%) and 28% (26-30%) respectively; in randomized trials, it was 32% (25-39%) and 28% (26-30%), respectively. In observational primary care and community-based studies, 45% (30-60%) of participants reported persistent GERD symptoms. Overall, persistent GERD symptoms despite PPI treatment were more likely in studies with a higher proportion of female participants [>60% vs. <50%, risk ratio (RR): 3.66; P < 0.001], but less likely in studies from Europe than in those from the USA (RR: 0.71; P < 0.001), and were associated with decreased psychological and physical well-being.

CONCLUSIONS

Persistent GERD symptoms despite PPI treatment are common in the primary care and community setting. Alternative approaches to management are required.

Effects of lesogaberan on reflux and lower esophageal sphincter function in patients with gastroesophageal reflux disease

BACKGROUND & AIMS

Transient lower esophageal sphincter relaxations (TLESRs) are a major mechanism behind reflux. This study assessed the effects of lesogaberan (AZD3355), a novel gamma-aminobutyric acid type B receptor agonist, on reflux and lower esophageal sphincter (LES) function when used as add-on treatment in patients with reflux symptoms despite proton pump inhibitor (PPI) treatment.

METHODS

In this randomized, double-blind, placebo-controlled, crossover study, patients received lesogaberan (65 mg) or placebo twice on day 1 (morning/evening) and once on day 2 (morning), in addition to existing PPI treatment. Patients consumed a standardized meal 45-60 minutes after morning doses. Ambulatory impedance-pH monitoring was conducted for 24 hours after the first dose on day 1. Stationary manometry and impedance-pH monitoring was conducted for 4 hours after the third dose on day 2.

RESULTS

Of 27 randomized patients, 21 were included in the per-protocol efficacy analysis. During the 24 hours after treatment start, lesogaberan reduced the mean number of reflux events by approximately 35% compared with placebo. During the 3 postprandial hours on day 2, lesogaberan reduced the geometric mean number of TLESRs by 25% and increased geometric mean LES pressure by 28% compared with placebo. The most common adverse events were headache (placebo: 11/27 patients; lesogaberan: 8/25 patients) and paresthesia (transient; placebo: 3/27 patients; lesogaberan: 5/25 patients).

CONCLUSIONS

In patients with reflux symptoms despite PPI treatment, lesogaberan decreased the number of TLESRs and reflux episodes, and increased LES pressure compared with placebo. These findings support further evaluation of lesogaberan as an add-on treatment in patients partially responding to PPIs.

Effect of lesogaberan, a novel GABA(B)-receptor agonist, on transient lower oesophageal sphincter relaxations in male subjects

BACKGROUND

Transient lower oesophageal sphincter relaxations (TLESRs) are a major mechanism behind gastro-oesophageal reflux disease (GERD).

AIM

To assess the effect of lesogaberan (AZD3355) - a novel peripherally active GABA(B) receptor agonist - on TLESRs.

METHODS

Twenty-four healthy men were enrolled in this single-blind, placebo-controlled, randomized, single-centre, three-period crossover phase 1 study. Subjects were randomized to receive single oral doses of lesogaberan (0.8 mg/kg), baclofen (40 mg) and placebo, separated by washout periods of < or = 7 days. Subjects finished a meal 1 h after the dose. Oesophageal manometry and pH-metry measurements were taken during the 3 h after the meal.

RESULTS

Twenty-one subjects completed the study. Compared with placebo, lesogaberan 0.8 mg/kg significantly reduced the number of TLESRs by 36% [geometric mean ratio (GMR): 0.64; 95% confidence interval (CI): 0.51-0.82] and significantly reduced the number of acid reflux episodes (mean reduction: 1.6; 95% CI: 0.34-2.9). Lesogaberan also significantly increased lower oesophageal sphincter (LES) pressure by 39% compared with placebo (GMR: 1.39; 95% CI: 1.18-1.64). Comparable results were observed with baclofen. Similar numbers of adverse events were reported by subjects taking lesogaberan and placebo.

CONCLUSION

Compared with placebo, lesogaberan significantly reduced TLESRs and acid reflux episodes and increased LES pressure.

Guidelines for the diagnosis and management of gastroesophageal reflux disease: an evidence-based consensus

Gastroesophageal reflux disease (GERD) is one of the most common disorders in medical practice. A number of guidelines and recommendations for the diagnosis and management of GERD have been published in different countries, but a Brazilian accepted directive by the standards of evidence-based medicine is still lacking. As such, the aim of the Brazilian GERD Consensus Group was to develop guidelines for the diagnosis and management of GERD, strictly using evidence-based medicine methodology that could be clinically used by primary care physicians and specialists and would encompass the needs of physicians, investigators, insurance and regulatory bodies. A total of 30 questions were proposed. Systematic literature reviews, which defined inclusion and/or exclusion criteria, were conducted to identify and grade the available evidence to support each statement. A total of 11,069 papers on GERD were selected, of which 6,474 addressed the diagnosis and 4,595, therapeutics. Regarding diagnosis, 51 met the requirements for the analysis of evidence-based medicine: 19 of them were classified as grade A and 32 as grade B. As for therapeutics, 158 met the evidence-based medicine criteria; 89 were classified as grade A and 69 as grade B. In the topic Diagnosis, answers supported by publications grade A and B were accepted. In the topic Treatment only publications grade A were accepted: answers supported by publications grade B were submitted to the voting by the Consensus Group. The present publication presents the most representative studies that responded to the proposed questions, followed by pertinent comments. Follow examples. In patients with atypical manifestations, the conventional esophageal pH-metry contributes little to the diagnosis of GERD. The sensitivity, however, increases with the use of double-channel pH-metry. In patients with atypical manifestations, the impedance-pHmetry substantially contributes to the diagnosis of GERD. The examination, however, is costly and scarcely available in our country. The evaluation of the histological signs of esophagitis increases the diagnostic probability of GERD; hence, the observation of the dimensions of the intercellular space of the esophageal mucosa increases the probability of diagnostic certainty and also allows the analysis of the therapeutic response. There is no difference in the clinical response to the treatment with PPI in two separate daily doses when compared to a single daily dose. In the long term (>1 year), the eradication of H. pylori in patients with GERD does not decrease the presence of symptoms or the high recurrence rates of the disease, although it decreases the histological signs of gastric inflammation. It seems very likely that there is no association between the eradication of the H. pylori and the manifestations of GERD. The presence of a hiatal hernia requires larger doses of proton-pump inhibitor for the clinical treatment. The presence of permanent migration from the esophagogastric junction and the hernia dimensions (>2 cm) are factors of worse prognosis in GERD. In this case, hiatal hernias associated to GERD, especially the fixed ones and larger than 2 cm, must be considered for surgical treatment. The outcomes of the laparoscopic fundoplication are adequate.

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.

Overutilization of proton pump inhibitors: a review of cost-effectiveness and risk [corrected]

Proton pump inhibitors (PPIs) are superior to histamine-2 receptor antagonists for the treatment of gastroesophageal reflux disease (GERD) and erosive esophagitis. Antisecretory therapy (AST), however, accounts for significant cost expenditure in the United States including over-the-counter and prescription formulations. Moreover, emerging data illustrate the potential risks associated with long-term PPI therapy including variations in bioavailability of common medications, vitamin B12 deficiency, Clostridium difficile-associated diarrhea, community-acquired pneumonia, and hip fracture. For these reasons, it is imperative to use the lowest dose of drug necessary to achieve desired therapeutic goals. This may entail the use of step-down, step-off, or on-demand PPI therapy for the treatment of GERD. In addition, PPIs are the most commonly used medications for stress ulcer prophylaxis (SUP), despite little evidence to support their use. Compounding this problem is evidence that patients erroneously administered SUP are often discharged on long-term PPI therapy. Pharmacy-driven step-down orders, limitation of the use of PPIs for SUP in non-ICU settings, and meticulous chart review to ensure that hospitalized patients are not discharged home on a PPI without an appropriate indication are interventions that can ensure proper PPI utilization with minimal of risk and optimization of cost-effectiveness.

Systematic review: maintenance treatment of gastro-oesophageal reflux disease with proton pump inhibitors taken 'on-demand'

BACKGROUND

Proton pump inhibitors (PPI) therapy 'on-demand' is often used as an alternative to continuous maintenance therapy in gastro-oesophageal reflux disease (GERD).

AIM

We conducted a systematic review with the specific objectives to ascertain whether on-demand PPI therapy was effective in preventing symptomatic relapse and to assess the relative efficacy of on-demand vs. continuous PPI maintenance strategy.

METHODS

Randomized-controlled clinical trials comparing on-demand PPI vs. placebo or on-demand vs. continuous PPI therapy in GERD patients were identified by searching the Medline database and the Cochrane Controlled Trials Register.

RESULTS

Seventeen studies were found which met inclusion criteria. Out of the 17 studies: five investigated exclusively patients with non-erosive reflux disease (NERD), four patients with NERD and mild oesophagitis, two patients with erosive oesophagitis only, and two patients with uninvestigated GERD symptoms, respectively. Four further studies were not investigating the effectiveness of the therapies but primarily pharmacoeconomic or quality of life parameters.

CONCLUSIONS

On the basis of the analysis of 17 studies, we can conclude that on-demand therapy with currently available PPI appears to be effective in the long-term management of patients with NERD or mild and uninvestigated forms of GERD, but not in patients with (severe) erosive oesophagitis.

On-demand therapy for gastroesophageal reflux disease

The following pages summarize the proceedings of a symposium held in May 2006 on the emerging role of on-demand therapy for gastroesophageal reflux disease (GERD). Medical therapy for GERD has undergone significant change in recent years with the advent of effective, but expensive, antisecretory agents. On-demand (patient-driven) therapy is attractive to payers and patients, because it appears to be both cost-effective and convenient. Many individuals appear to accept occasional symptomatic breakthrough in exchange for personal control of their disease. On-demand therapy should be distinguished from intermittent therapy, which is either patient- or physician-driven, but which requires intermittent episodes of continuous therapy followed by discontinuation until symptoms recur. Proton pump inhibitors appear to be effective on-demand agents despite theoretical pharmacodynamic limitations for this class of drug. The available data support the use of on-demand therapy for GERD in uninvestigated reflux disease, nonerosive reflux disease, and possibly mild esophagitis as well. On-demand therapy should not be considered for patients with severe esophagitis.

Participation in a clinical trial influences the future management of patients with gastro-oesophageal reflux disease in general practice

BACKGROUND

The long-term effects of participation in trials has not been reported. A randomized-controlled trial (the ONE study) reported on the management of gastro-oesophageal reflux disease with esomeprazole in primary care, testing on-demand treatment vs. treatment courses.

AIM

To evaluate the impact of participation in a trial on General Practitioners management and patient behaviour.

METHODS

Management of gastro-oesophageal reflux disease was compared between General Practitioners who participated in ONE (ONE-GPs) and a random sample of General Practitioners who did not participate in ONE (Other-GPs). Symptom presentation and satisfaction with treatment was compared between patients who had participated in ONE (ONE-patients) and patients who had not (Other-patients).

RESULTS

ONE-GPs prescribed on-demand treatment with proton-pump inhibitors to 47% of the patients, Other-GPs to 27%. ONE-patients consulted for significantly less symptoms compared with Other-patients. ONE-patients reported significantly higher patient satisfaction compared with Other-patients. ONE-patients used 98 doses during 6 months whereas Other-patients used 76 doses.

CONCLUSIONS

Participation in a clinical trial influenced both doctors and patients. Treatment modalities introduced by the trial were used in daily practice by the General Practitioners. Patients who had participated in the trial consulted for less symptoms and used more medication, compared with patients who did not participate.

An evidence-based, Latin-American consensus on gastro-oesophageal reflux disease

In recognition of the high prevalence of gastro-oesophageal reflux disease (GORD) and its importance in Latin America, the InterAmerican Association of Gastroenterology and the InterAmerican Society of Digestive Endoscopy organized a Latin-American Consensus on GORD in Cancun, Mexico in September 2004. The main objectives of the consensus meeting were to provide evidence-based guidance with respect to the diagnosis and treatment of GORD, relevant to all countries in the region. The methodology, results and recommendations of the consensus are described in detail.

Efficiency of potent gastric acid inhibition

The evidence regarding the efficiency of potent gastric acid inhibition is exposed after a systematic search and a critical evaluation of its quality, using a specific score. The aim was to review alternative options, in economic terms, especially related with gastro-oesophageal reflux disease. The results show that the superiority of the proton pump inhibitors over the histamine H2 receptor antagonist is clear in moderate and severe oesophagitis and in patients with persistent or severe symptoms. This evidence is clearly related with the intensity of the gastric inhibition. An associated benefit is the improvement of the quality of life obtained with this potent gastric acid inhibition profile.

Review article: gastro-oesophageal reflux disease--the health economic implications

For the vast majority of patients with gastro-oesophageal reflux disease appropriate care involves the management of symptoms with lifestyle advice and drugs. However, there is dissension about the appropriate use of endoscopy, whether drugs should be stepped up or down according to potency, how long drugs should be used for, the role of lifestyle advice, and, related to this, the role of patients' lifestyle choices. This exploration of the economics of gastro-oesophageal reflux disease reviews its cost burden to the UK, assesses published economic models for their strengths and weaknesses and examines current recommendations for gastro-oesophageal reflux disease management from a socioeconomic perspective. Drugs prescribed predominantly for dyspepsia cost the UK National Health Service a projected pound sterling 625 million in 2004, 7% of the primary care prescribing budget. When general practitioners consultations, endoscopies, over-the-counter sales and sickness absences are included the UK cost rises to pound sterling 1.5 billion: approximately half of this cost can be ascribed to gastro-oesophageal reflux disease. Emphasis upon regular review and stepping down treatment (while maintaining adequate symptom relief) is both clinically appropriate and resource efficient. Other cost-effectiveness issues largely lack objective answers because investment in treatment for gastro-oesophageal reflux disease depends upon how much more, at the margin, society wishes to invest for further but diminishing symptom relief.

Daily treatment with esomeprazole is superior to that taken on-demand for maintenance of healed erosive oesophagitis

BACKGROUND

On-demand therapy with esomeprazole is effective for long-term treatment of non-erosive gastro-oesophageal reflux disease, but it has not been evaluated in erosive gastro-oesophageal reflux disease.

AIMS

To compare endoscopic and symptomatic remission over a 6-month period when patients with healed erosive gastro-oesophageal reflux disease are treated with esomeprazole 20 mg, either once daily or on-demand.

METHODS

Patients with verified erosive reflux oesophagitis of Los Angeles grades A-D were enrolled. Following 4-8 weeks treatment with esomeprazole 40 mg daily, those who were endoscopically healed and had symptom control during the last week were randomized to maintenance therapy for 6 months with esomeprazole 20 mg, taken either once daily or on-demand.

RESULTS

Of 539 enrolled patients, 494 (91%) were healed at 8 weeks and 477 were randomized to maintenance therapy with esomeprazole 20 mg, 243 once daily and 234 on-demand. After once daily treatment, 81% of patients were still in remission at 6 months, compared with only 58% who took on-demand treatment (P < 0.0001). A difference in remission was found irrespective of baseline grade of oesophagitis, but it was more pronounced for the more severe grades. There was no difference in overall symptomatic remission between the two treatments, although heartburn was significantly more prevalent in the on-demand group.

CONCLUSIONS

Once daily esomeprazole 20 mg was better than that taken on-demand for maintaining healed erosive oesophagitis, regardless of baseline Los Angeles grade.

Treatment of uncomplicated reflux disease

Uncomplicated reflux disease comprises the non-erosive reflux disease (NERD) and erosive reflux disease (ERD). The objectives of treatment are the adequate control of symptoms with restoration of quality of life, healing of lesions and prevention of relapse. Treatment of NERD consists in the administration of proton pump inhibitors (PPI) for 2-4 wk, although patients with NERD show an overall poorer response to PPI treatment than patients with ERD owing to the fact that patients with NERD do not form a pathophysiologically homogenous group. For long-term management on-demand treatment with a PPI is probably the best option. In patients with ERD, therapy with a standard dose PPI for 4-8 wk is always recommended. Long-term treatment of ERD is applied either intermittently or as continuous maintenance treatment with an attempt to reduce the daily dosage of the PPI (step-down principle). In selected patients requiring long-term PPI treatment, antireflux surgery is an alternative option. In patients with troublesome reflux symptoms and without alarming features empirical PPI therapy is another option for initial management. Therapy should be withdrawn after initial success. In the case of relapse, the long-term care depends on a careful risk assessment and the response to PPI therapy.

Effects of pantoprazole 20 mg in mildgastroesophageal reflux disease: Once-daily treatment in the acute phase, and comparison of on-demand versus continuous treatment in the long term

BACKGROUND

Gastroesophageal reflux disease (GERD) is a chronic disorder,and although effective short-term treatment strategies are known, the rate of relapse within 1 year is as high as 90% despite successful acute treatment. Consequently, most patients with GERD require an effective long-term management strategy to achieve adequate symptom control and maintain mucosal healing.

OBJECTIVE

The present study was undertaken to compare the control ofGERD symptoms during long-term (24-week) treatment with pantoprazole 20 mg used on-demand or continuously in patients with mild GERD after complete relief of acute GERD symptoms.

METHODS

Patients with endoscopically confirmed Savary/Miller grade 0(normal mucosa) or I (patchy red lesions without white coating or with central white coating) GERD were enrolled in this multinational, multicenter study comprising 2 phases. In the first phase, which was open label, patients were treated with pantoprazole 20 mg QD for 4 weeks. The presence and intensity of the symptoms of heartburn, acid regurgitation, and pain on swallowing were assessed. In the second phase, which was an open-label, 24-week, randomized design, only patients completely free of GERD symptoms after acute treatment were included. During this phase, on-demand treatment with pantoprazole 20 mg was directly compared with continuous treatment. The rate of failure to control GERD symptoms after 24 weeks of treatment was estimated using the Kaplan-Meier method. Subsequently, the difference between treatments (on-demand minus continuous) and its 95% CI were calculated, and the on-demand treatment was tested for noninferiority using a predefined noninferiority margin of 20%. The mean daily symptom loads were compared between the treatment groups using the 1-sided Wilcoxon rank sum test on a 5% α level. The point estimate of the difference was determined using the Hodges-Lehman estimator and the 1-sided 95% CI according to Moses. The number of patients unwilling to continue due to insufficient control of heartburn, acid regurgitation, and pain on swallowing was analyzed using the Kaplan-Meier (time-to-event) analysis. Analysis was performed in the same manner as for the rate of failure to control GERD symptoms, but the 95% CI was interpreted for statistical superiority.

RESULTS

A total of 558 patients were enrolled in this study. At the end of theacute phase, 82.1% of patients in the per-protocol (PP) population and 79.1% in the intent-to-treat (ITT) population were relieved of all GERD symptoms, and subsequently entered the long-term phase. After 24 weeks of treatment, analysis of the failure rates revealed that on-demand treatment was noninferior to continuous treatment because the 95% CI was completely below 20% (ITT, 12.1% difference [95% CI, -∞ to 18.9%]; PP, 10.1% difference [95% CI, -∞ to 17.7%]). The higher perceived mean (SD) daily symptom load in the on-demand group (ITT, 1.26 [1.491 vs 0.82 [1.341) was balanced by the reduced tablet intake in that group (PP, 0.51 [0.31 ] vs 0.97 [0.11 ] tablets/d; P < 0.001). With respect to the rate of patients unwilling to continue treatment, no statistically significant difference was observed between the on-demand and continuous groups (ITT/PP, 0.95/1.13 vs 0.95/1.26).

CONCLUSIONS

In this study of pantoprazole 20 mg tablets in patients withmild GERD, patients receiving on-demand treatment benefited despite their higher symptom load. The similar rates of unwillingness to continue treatment in both groups might suggest that patients were satisfied with the on-demand treatment strategy. On-demand treatment with pantoprazole 20 mg was found to be noninferior compared with continuous therapy with regard to symptom control. Both on-demand and continuous treatments were well tolerated.

Systematic review: the efficacy of intermittent and on-demand therapy with histamine H2-receptor antagonists or proton pump inhibitors for gastro-oesophageal reflux disease patients

AIM

To perform a systematic review on the efficacy of intermittent and on-demand therapy with either histamine H2-receptor antagonists or proton pump inhibitors for patients with erosive oesophagitis or symptomatic heartburn.

METHOD

We conducted randomized-controlled trials of non-continuous therapy in gastro-oesophageal reflux disease patients.

RESULTS

Fourteen studies met inclusion criteria. Because of variation in outcome measures statistical pooling of results was not possible. Results were analysed qualitatively. Four studies evaluated intermittent therapy of treatment 3 days a week with omeprazole 20 mg or daily with ranitidine which were not efficacious compared to a daily proton pump inhibitor. Famotidine 10 and 20 mg, ranitidine 75 mg and cimetidine 200 mg were efficacious in five on-demand studies for relief of symptomatic heartburn episodes. In three of four studies, evaluating only non-erosive (endoscopy-negative) gastro-oesophageal reflux disease patients, esomeprazole 20 and 40 mg and omeprazole 10 and 20 mg a day were efficacious using willingness to continue as an endpoint. Lansoprazole 30 mg and omeprazole 20 mg maintained symptom control in 60-70% of healed oesophagitis patients.

CONCLUSIONS

Intermittent proton pump inhibitor or H2-receptor antagonist therapy is not effective in maintaining control in oesophagitis patients. H2-receptor antagonists are effective for relief of heartburn episodes. On-demand proton pump inhibitor therapy may work in a proportion of non-erosive gastro-oesophageal reflux disease patients.