Concomitant irritable bowel syndrome is associated with failure of step-down on-demand proton pump inhibitor treatment in patients with gastro-esophageal reflux disease

Approaches to Deprescribing Proton Pump Inhibitors in Clinical Practice: A Systematic Review

Background: Proton pump inhibitors (PPIs) are some of the most frequently prescribed medications, but they are often used inappropriately, either being prescribed without a clear indication or continued for longer than necessary. In such cases, deprescribing is recommended. However, despite its proven effectiveness, the implementation of deprescribing in clinical practice remains inconsistent and varied, making it challenging to identify the most effective strategies. The goal is to provide a comprehensive outline of deprescribing interventions for PPI therapy implemented across various settings and by different healthcare professionals. Methods: The study is designed to be a systematic review of the published literature. PubMed, Embase, and Web of Science databases were searched from 1 January 1989 (the first PPI on the market) to 30 September 2024 for articles assessing PPI deprescribing in adult patients, focusing on the implementation rate (primary outcome) or effects on symptoms (secondary outcome). Results: After screening, 66 studies were included, predominantly pragmatic trials (N = 32) or randomized controlled trials (N = 25). We found a variety of interventions promoting PPI deprescription. Collaborative efforts involving multiple healthcare professionals, the use of algorithms for clinical decision-making, and patient involvement have proven to be key elements in the most effective strategies. Discontinuing therapy may not be advisable in cases of recurrent symptoms, suggesting that on-demand therapy could be a recommended approach. Deprescribing is particularly relevant for individuals with mild illnesses and symptoms, where tapering can effectively mitigate the rebound symptoms often associated with abrupt discontinuation. Conclusions: Given the current prevalence of inappropriate PPI prescribing, it is imperative to raise awareness among both physicians and patients about the importance of the deprescribing process, which should be tailored to the specific needs of each patient, considering his/her medical history, current health status, and personal preferences.

Predicting factors of recurrence in patients with gastroesophageal reflux disease: a prospective follow-up analysis

BACKGROUND

Recurrence of gastroesophageal reflux disease (GERD) is common among patients who are no longer receiving proton pump inhibitors (PPIs). This study investigated factors associated with GERD recurrence.

METHODS

We included 499 consecutive GERD patients who completed validated reflux and psychological questionnaires before undergoing upper endoscopy. All patients were treated with PPIs and followed up.

RESULTS

Recurrence was observed in 89 (30.4%) of 293 patients during the 1-year follow up. Patients with recurrence had a higher prevalence of diabetes mellitus (p = 0.037), higher baseline GERD Questionnaire (GERDQ) scores (p = 0.002), and higher Pittsburgh Sleep Quality Index scores (p = 0.045). Log-rank analysis showed that a GERDQ score of ⩾8 was independently associated with an increased recurrence risk (p = 0.002). The scores of all psychological questionnaires and health-related quality of life questionnaire worsened more at the end of follow up in patients with recurrence than in those without recurrence. Multivariate analysis revealed that a higher GERDQ score was the only independent risk factor for GERD recurrence (p = 0.024). GERD patients who have greater initial symptom burden will have a higher recurrence rate after discontinuing PPIs.

CONCLUSIONS

GERD patients with greater initial symptom burden are more likely to have recurrence after discontinuing PPIs. This study highlights the importance of developing a new strategy to prevent GERD recurrence in the management of this common disorder.

Gastroesophageal reflux disease, functional dyspepsia and irritable bowel syndrome: common overlapping gastrointestinal disorders

Several studies have indicated an overlap between gastroesophageal reflux disease (GERD) and various functional gastrointestinal disorders (FGIDs). The overlapping conditions reported have mainly been functional dyspepsia (FD) and irritable bowel syndrome (IBS). The available literature is frequently based on symptomatic questionnaires or endoscopic procedures to diagnose GERD. Rarely, among patients with heartburn, pathophysiological evaluations have been considered to differentiate those with proven GERD from those without. Moreover, both GERD and IBS or FD showed enormous heterogeneity in terms of the criteria and diagnostic procedures used. The GERD-IBS overlap ranges from 3-79% in questionnaire-based studies and from 10-74% when GERD has been diagnosed endoscopically. The prevalence of functional dyspepsia (after normal upper endoscopy) is 12-15% and an overlap with GERD has been reported frequently. Only a few studies have considered a potential overlap between functional heartburn (FH) and IBS using a 24-h pH-metry or impedance-pH evaluation. Similar data has been reported for an overlap between FH and FD. Recently, a revision of the Rome criteria for esophageal FGIDs identified both FH and hypersensitive esophagus (HE) as potential functional esophageal disorders. This might increase the potential overlap between different FGIDs, with FH and HE rather than with GERD. The aim of the present review article was to appraise and discuss the current evidence supporting the possible concomitance of GERD with IBS and FD in the same patients and to evaluate how various GERD treatments could impact on the quality of life of these patients.

Persistent gastro-oesophageal reflux symptoms despite proton pump inhibitor therapy

About one-third of patients with suspected gastro-oesophageal reflux disease (GERD) do not respond symptomatically to proton pump inhibitors (PPIs). Many of these patients do not suffer from GERD, but may have underlying functional heartburn or atypical chest pain. Other causes of failure to respond to PPIs include inadequate acid suppression, non-acid reflux, oesophageal hypersensitivity, oesophageal dysmotility and psychological comorbidities. Functional oesophageal tests can exclude cardiac and structural causes, as well as help to confi rm or exclude GERD. The use of PPIs should only be continued in the presence of acid reflux or oesophageal hypersensitivity for acid reflux-related events that is proven on functional oesophageal tests.

Factors affecting response to proton pump inhibitor therapy in patients with gastroesophageal reflux disease: a multicenter prospective observational study

BACKGROUND

Proton pump inhibitor (PPI) therapy, the first-line treatment for gastroesophageal reflux disease (GERD), is not always effective. This study aimed to examine the effect of pretreatment patient characteristics on response to PPI therapy.

METHODS

Japanese outpatients with symptomatic GERD scheduled to receive endoscopy and PPI therapy were enrolled in this multicenter prospective observational study. The patients' characteristics, including GERD and dyspeptic symptoms, anxiety, depression, and quality of life, were assessed using questionnaires before and 2 and 4 weeks after the start of PPI therapy. Factors affecting therapeutic response were examined by simple and multiple regression analyses using three patient-reported outcome measures as objective variables.

RESULTS

Data from 182 patients were analyzed. In multiple regression analysis using the residual symptom rate as an objective variable, lower GERD symptom score (p < 0.05), absence of erosive esophagitis (p < 0.05), higher epigastric pain/burning symptom score (p < 0.05), and higher depression subscale score (p < 0.05) accompanied poorer therapeutic response. In analyses using the patient's impression of therapy, lower GERD symptom score (p < 0.05) and absence of erosive esophagitis (p < 0.05) accompanied poorer therapeutic response. In analyses using the relative GERD symptom intensity evaluated using a numeric rating scale, lower GERD symptom score (p < 0.05), higher epigastric pain/burning symptom score (p < 0.1), and lower body mass index (p < 0.05) accompanied poorer therapeutic response.

CONCLUSIONS

Patients who complained of milder GERD symptoms before treatment were likely to have poorer response to PPI therapy. Association of absence of erosive esophagitis, severer epigastric pain/burning symptoms, lower body mass index, and severer depression with poorer therapeutic response was also suggested.

Refractory gastroesophageal reflux disease: advances and treatment

'Refractory gastroesophageal reflux disease' is one of the most common misnomers in the area of gastroesophageal reflux disease. The term implies reflux as the underlying etiology despite unresponsiveness to aggressive proton pump inhibitor therapy. The term should be replaced with 'refractory symptoms.' We must acknowledge that in many patients symptoms of reflux often overlap with non-GERD causes such as gastroparesis, dyspepsia, hypersensitive esophagus and functional disorders. Lack of response to aggressive acid suppressive therapy often leads to diagnostic testing. In majority of patients these tests are normal. The role of non-acid reflux in this group is uncertain and patients should not undergo surgical fundoplication based on this parameter. In patients unresponsive to acid suppressive therapy GERD is most commonly not causal and a search for non-GERD causes must ensue.

New Approaches to Management of PPI-Refractory Gastroesophageal Reflux Disease

OPINION STATEMENT

"Refractory GERD" is one the most common misnomers in the area of gastroesophageal reflux disease. The term implies reflux as the underlying etiology despite unresponsiveness to aggressive, often twice-daily proton pump inhibitor therapy. The term should be replaced with "refractory symptoms." We must acknowledge that in many patients, symptoms of reflux often overlap with non-GERD causes such as gastroparesis, dyspepsia, hypersensitive esophagus, and functional disorders. Lack of response to aggressive acid suppressive therapy often leads to esophagogastroduodenoscopy followed by pH or impedance monitoring. In the majority of patients these tests are normal. The role of non-acid reflux measured by impedance pH testing in this group is uncertain at best and the results from this test alone should not be used to refer patients to surgical fundoplication. In patients unresponsive to acid suppressive therapy, reflux is most commonly not causal and a search for non-GERD causes must ensue.

Endotherapy for and tailored approaches to treating GERD, and refractory GERD

This paper presents commentaries on how endoluminal antireflux procedures compare to laparoscopic fundoplication; new endoscopic procedures being studied to treat refractory gastroesophageal reflux disease (GERD); the new Stretta; the relationship between obesity and proton pump inhibitor (PPI) resistance; data concerning acid hypersensitivity and sensory receptors (vallinoid, TRPV1) causing refractory GERD; whether microscopic esophagitis is relevant in determining symptoms of non-erosive reflux disease (NERD); how concomitant functional gastrointestinal disorders affect the PPI response in NERD; the evidence that a functional esophagus is associated with inflammatory bowel syndrome (IBS); the role of GABA agonists in the treatment of refractory GERD; the role of biofeedback and antidepressants in refractory GERD; and endoluminal fundoplication using the EsophyX device.

Psychological distress is not associated with treatment failure in patients with gastroesophageal reflux disease

OBJECTIVE

Symptoms of anxiety and depression are common in patients with gastroesophageal reflux disease (GERD). We aim to examine the relationship between psychological distress and response to proton pump inhibitors (PPI).

METHODS

In this prospective study, GERD patients receiving PPI once or twice daily were divided into 3 groups: responders to PPI once daily (group A, N=111), non-responders to PPI once daily (group B, N=78) and non-responders to PPI twice daily (group C, N=56). All patients completed demographic and clinical questionnaires, Rome III Diagnostic Questionnaire for irritable bowel syndrome, Hospital Anxiety and Depression Scale (HADS), Satisfaction with Life Scale (SWLS) and the Gastroparesis Cardinal Symptom Index (GCSI) questionnaires.

RESULTS

A total of 245 patients (59.3% females, 52±17.2 years) participated in this study. No differences were observed between groups with respect to age, sex, psychiatric medications or pre-existing major depression. Anxiety (HADS-anxiety>7) was seen in 32%, 31% and 34% of groups A, B and C, respectively (p=ns). Depression (HADS-depression>7) was present in 30%, 31% and 21% of groups A, B and C, respectively (p=ns). Global satisfaction with life (SWLS>20) was present in 63% of group C patients, compared to 78% of group A and 78% of group B (p=0.04, p=0.05, respectively). GCSI scores (mean±SD) were 11.1±9.2, 14.07±8.5 and 16.3±10.4, for groups A, B and C, respectively (p=0.002). GCSI correlated significantly with HADS-anxiety (r=0.20, p=0.002) and SWLS (r=-0.2, p=0.01).

CONCLUSION

Lack of response to PPI was associated with lower life satisfaction but not anxiety or depression. Symptoms suggestive of gastroparesis were associated with anxiety and low satisfaction with life in patients with GERD.

Overlap of functional heartburn and gastroesophageal reflux disease with irritable bowel syndrome

Several studies indicate a significant degree of overlap between irritable bowel syndrome (IBS) and gastroesophageal reflux disease (GERD). Likewise, both functional heartburn (FH) and IBS are functional digestive disorders that may occur in the same patients. However, data establishing a solid link between FH and IBS are lacking, mainly because the clinical definition of FH has undergone substantial changes over the years. The available literature on the overlap between GERD or FH and IBS highlights considerable heterogeneity in terms of the criteria and diagnostic procedures used to assess heartburn and IBS. In particular, several epidemiological studies included patients with concomitant IBS and GERD without any attempt to distinguish FH (as defined by the Rome III criteria) from GERD via pathophysiological investigations. Independent of these critical issues, there is preliminary evidence supporting a significant degree of FH-IBS overlap. This underscores the need for studies based on updated diagnostic criteria and accurate pathophysiological classifications, particularly to distinguish FH from GERD. This distinction would represent an essential starting point to achieving a better understanding of pathophysiology in the subclasses of patients with GERD and FH and properly assessing the different degrees of overlap between IBS and the subcategories of heartburn.The present review article intends to appraise and critically discuss current evidence supporting a possible concomitance of GERD or FH with IBS in the same patients and to highlight the pathophysiological relationships between these disorders.

Predictors of clinical response of acid suppression in Chinese patients with gastroesophageal reflux disease

BACKGROUND

Up to 40% of patients with gastroesophageal reflux disease fail to respond to proton pump inhibitor therapy.

AIMS

To determine predictors of clinical response of proton pump inhibitor therapy.

METHODS

Consecutive patients with gastroesophageal reflux disease were enrolled prospectively. All patients underwent upper endoscopy and 24-h multichannel intraluminal impedance and pH monitoring before receiving esomeprazole 20 mg b.i.d. for 2 months. Multivariate logistic regression analysis was used to determine the independent predictors of clinical response to proton pump inhibitor therapy.

RESULTS

A total of 204 patients with typical reflux symptoms were recruited and screened. Among them 153 patients (mean age 46.3 ± 10.6 years, 51.0% female) completed all the examinations and were assigned to proton pump inhibitor therapy. Ninety-five patients (62.1%) responded to acid suppression after 2 months. Multivariate logistic analysis showed that the predictor for response was pathological distal esophageal acid reflux (P = 0.001). The factors associated with proton pump inhibitor therapy failure were the presence of irritable bowel syndrome alone (P = 0.006), depression (P = 0.005), and overlap of irritable bowel syndrome and functional dyspepsia (P = 0.002).

CONCLUSIONS

The clinical response of acid suppression on gastroesophageal reflux disease could be predicted by clinical and pH parameters rather than impedance data.

Partial response to proton pump inhibitor therapy for GERD: observational study of patient characteristics, burden of disease, and costs in the USA

Background

Disease burden and associated costs are not well understood among patients with gastroesophageal reflux disease (GERD) who have persistent symptoms despite optimized proton pump inhibitor (PPI) therapy. The aim of this study was to investigate disease burden and costs of GERD in partial responders to PPI therapy.

Methods

The Partial Response to PPI treatment: the Cost to Society and the Burden to the Patient in the US (REMAIN US) study was a 12-month, multicenter, noninterventional, observational study of 552 partial PPI responders in the USA. Participating sites were comprised of family practice (n = 30), internal medicine (n = 8), and specialist (gastroenterologist) centers (n = 15). GERD symptoms, health-related quality of life (HRQL), and impact on productivity were evaluated from patient-reported outcome instruments. Resource utilization data were also collected.

Results

Patients had a high symptom burden, impaired HRQL, and reduced productivity while at work and in daily activities, despite optimized PPI therapy. Mean annual GERD-related costs were US$9944 per patient, comprising total direct costs and mean productivity loss costs of US$4068 and US$5876 per patient, respectively.

Conclusion

Patients with GERD and a partial response to PPI therapy have considerable direct and indirect costs, along with substantial impairments in HRQL and productivity.

Prevalence of gastro-esophageal reflux-type symptoms in individuals with irritable bowel syndrome in the community: a meta-analysis

OBJECTIVES

Irritable bowel syndrome (IBS) and gastro-esophageal reflux-type symptoms (GERS) are highly prevalent in the general population, and the two appear to be related. We conducted a systematic review and meta-analysis to estimate the prevalence of GERS in individuals with IBS, and to quantify the overlap between the two disorders.

METHODS

MEDLINE, EMBASE, and EMBASE Classic were searched (up to October 2011) to identify population-based studies reporting the prevalence of IBS and GERS in adults (≥ 15 years), defined using a specific symptom-based criteria or a questionnaire. The prevalence of IBS and GERS were extracted for all studies. Pooled prevalence, according to study location and criteria used to define IBS or GERS, as well as odds ratios (OR), with 95% confidence intervals (CIs) were calculated. The degree of overlap between the two was examined.

RESULTS

Of 390 papers evaluated, 81 reported prevalence of IBS. Thirteen of these, containing 49,939 participants, reported the proportion of individuals with GERS. The prevalence of GERS in IBS was 42.0% (95% CI, 30.0-55.0). The pooled OR for GERS in individuals with IBS, compared with those without, was 4.17 (95% CI, 2.85-6.09). The OR for GERS in IBS remained significantly higher in all geographical regions studied, and for all diagnostic criteria used. The degree of overlap between the two conditions varied from 14.2, when the Rome II criteria for IBS were used, to 26.7% with the Manning criteria.

CONCLUSIONS

The OR of GERS in individuals with IBS was four-fold that of individuals without IBS. Reasons for this remain speculative, but may include shared pathophysiological mechanisms or residual confounding.

Prevalence, comorbidity, and risk factors for functional bowel symptoms: a population-based survey in Northern Norway

OBJECTIVE

To assess the occurrence of functional bowel (FB) symptoms in Northern Norway, and to describe gender differences, comorbidity, and association to risk factors, including Helicobacter pylori infection.

MATERIALS AND METHODS

Adult subjects (18-85 years) from the communities Bodø and Sørreisa were invited to complete a questionnaire on gastrointestinal symptoms, and to provide stool samples for assessment of H. pylori.

RESULTS

Of 3927 invited subjects, 1731 (44.1%) responded to the questionnaire and 1416 (36.0%) provided stool samples. Functional bowel symptoms were found in 25%, somewhat more frequent in females (28.6%). Symptom pattern differed between genders only with regard to constipation. Presence of FB symptoms was significantly associated with gastroesophageal reflux symptoms, headache, dizziness, palpitations, sleep disturbances, and musculoskeletal symptoms. Psychometric traits were also more prevalent: feeling of low coping ability, feeling depressed, feeling of time pressure, and a low self-evaluation of health. In a multivariate regression model, factors that influenced the reporting FB symptoms were male gender (OR 0.71, 95% CI (0.52; 0.96)), age 50-69 years or ≥70 years (OR 0.49 (0.30; 0.80) and 0.40 (0.21; 0.79)), obesity (OR 1.61 (1.05; 2.47)), NSAID use (OR 2.50 (1.63; 3.83)), and previous abdominal surgery (OR 1.54 (1.05; 2.26)). The presence of H. pylori was not associated with FB symptoms.

CONCLUSIONS

Functional bowel symptoms are prevalent, but our findings may be prone to self-selection bias. FB symptoms carry a significant burden of comorbidity. Female gender and low age are known risk factors for FB symptoms, whereas NSAID use as a risk factor deserves further clarification.