Randomised clinical trial: identification of responders to short-term treatment with esomeprazole for dyspepsia in primary care - a randomised, placebo-controlled study

Gastric pH and Therapeutic Responses to Exsomeprazole in Patients With Functional Dyspepsia: Potential Clinical Implications

BACKGROUND

Therapy for functional dyspepsia remains a challenge. This study aimed to evaluate esomeprazole (E) versus placebo (P) regarding (1) the effectiveness in providing relief of abdominal pain or discomfort during 16 weeks of therapy in patients with functional dyspepsia having moderate or severe symptoms; (2) the effects on gastric acid suppression and (3) the relationship between symptom relief and gastric pH.

METHODS

Enrolled patients were randomized to E (n = 38) or P (n = 35) in a double-blind, placebo-controlled trial. Outcomes were measured at four 4-week intervals. Drug dose titrated at each visit, based on relief of abdominal symptoms. The 24-hour gastric pH was monitored at baseline, 4 and 8 weeks.

RESULTS

After 4 weeks, 71% of E patients (40mg) reported satisfactory symptom relief versus 34% of P patients (P < 0.001). When the dose for nonresponders (NR) was titrated to 40mg twice daily, the E relief rate increased to 82% versus 56% in P group (P < 0.05). During the next 4 weeks, with dose decreased by half in responders, E response rate declined to 69% versus 48% in P group (P < 0.10). When the dose was increased for NR during the last 4 weeks, E rate increased to 83% versus 57% in P group (P < 0.05). At 4 and 8 weeks for E responders and NR, patients׳ pH >4 value increased significantly compared to baseline.

CONCLUSIONS

(1) Though E 40mg once daily is superior to P, some patients benefit from 40mg twice daily; (2) E, 40mg once daily, profoundly inhibits gastric acid secretion; (3) intragastric pH monitoring before and after therapy may help address the relationship between symptomatic relief and gastric acid secretion and (4) some patients respond to monitored titrated placebo therapy.

Visceral hypersensitivity and electromechanical dysfunction as therapeutic targets in pediatric functional dyspepsia

Functional gastrointestinal disorders (FGID) are common clinical syndromes diagnosed in the absence of biochemical, structural, or metabolic abnormalities. They account for significant morbidity and health care expenditures and are identifiable across variable age, geography, and culture. Etiology of abdominal pain associated FGIDs, including functional dyspepsia (FD), remains incompletely understood, but growing evidence implicates the importance of visceral hypersensitivity and electromechanical dysfunction. This manuscript explores data supporting the role of visceral hypersensitivity and electromechanical dysfunction in FD, with focus on pediatric data when available, and provides a summary of potential therapeutic targets.

Dyspepsia

Dyspepsia is a complex disorder with several distinct pathophysiologic mechanisms that are still poorly understood. Patients who experience dyspepsia have a high burden of disease, with significant personal and economic costs. Although serious pathology presenting as dyspepsia is rare, clinicians need to be aware of alarm features that should trigger prompt referral for subspecialty care. Those without alarm features can be managed in a rational way with either empiric antisecretory therapy, test-and-treat for H pylori eradication, antidepressants, and psychotherapy, or a combination of these. Given the heterogeneity of symptoms and large variability in response to different treatments, more research into specific pathophysiologic mechanisms will likely help guide diagnosis and treatment choices in the future.

Therapeutic effects of famotidine on chronic symptomatic gastritis: subgroup analysis from FUTURE study

BACKGROUND

A therapeutic strategy for symptomatic patients with chronic gastritis has not been established. Gastric acid has been reported to induce a variety of unpleasant abdominal symptoms. We investigated whether the histamine H2 receptor antagonist famotidine attenuated upper abdominal symptoms in patients with chronic gastritis.

METHODS

In this multicenter prospective single-arm open-label study, 10,311 patients with a clinical diagnosis of chronic symptomatic gastritis were enrolled and each patient was administered famotidine at 20 mg/day for 4 weeks. The intensity levels of upper abdominal symptoms, epigastralgia, epigastric fullness, and heartburn were evaluated using a face scale (grade 0-4). Abdominal symptom-related quality of life (QOL) impairment was also evaluated, using an Izumo scale before and after famotidine administration. In a subgroup analysis, symptomatic responses in patients diagnosed with functional dyspepsia (FD) according to the Rome III criteria were analyzed.

RESULTS

In 8,460 patients who completed the protocol, famotidine administration significantly attenuated epigastralgia, epigastric fullness, and heartburn, and famotidine also attenuated abdominal symptom-related QOL impairment in all patients with chronic symptomatic gastritis, in those with FD-like symptoms without organic disease, and in those with FD as defined by the Rome III criteria.

CONCLUSION

Famotidine is effective to relieve abdominal symptoms and improve QOL, not only in patients with Rome III-defined FD, but also in those with chronic symptomatic gastritis.

Characteristics of Japanese patients with chronic gastritis and comparison with functional dyspepsia defined by ROME III criteria: based on the large-scale survey, FUTURE study

OBJECTIVE

To clarify the clinical characteristics of patients diagnosed with chronic gastritis in Japan, a large scale clinical survey of patients with chronic upper gastrointestinal symptoms was conducted. Patients diagnosed with functional dyspepsia (FD) according to the ROME III criteria were selected from among patients with chronic gastritis and the clinical characteristics of patients with FD and those with chronic gastritis were compared.

PATIENTS AND METHODS

Patients with upper abdominal symptoms and diagnosed with chronic gastritis were enrolled in the study. Their main complaints, duration of symptoms, clinical characteristics, mental state, and results of endoscopic examinations, if available, were prospectively surveyed. Quality of life (QOL) impairment caused by abdominal symptoms was also surveyed using the Izumo QOL scale.

RESULTS

A total of 9,125 patients with a clinical diagnosis of chronic gastritis were enrolled in the survey. Of those, approximately 60% had more than 2 symptoms and QOL impairment was greater in cases with multiple symptoms. Endoscopic examinations were performed in 2,946 cases (32.3% of enrolled patients), during which gastric and/or esophageal carcinoma was found in only 0.2%, though organic diseases were found in 6.2%. Endoscopic examinations were not done for patients with high risks of organic diseases. Of patients with organic diseases excluded by an endoscopic examination, only 362 (12.3% of patients who underwent an endoscopy) were diagnosed with FD according to the ROME III criteria, mainly because of short symptom duration. There were no remarkable differences in regard to clinical characteristics, including symptoms and mental state, between patients with chronic gastritis and those with FD.

CONCLUSION

Clinical characteristics of patients with chronic gastritis were similar to those with FD, except for shorter symptom duration.