The effect of antireflux treatment on patients with gastroesophageal reflux disease undergoing a mental arithmetic stressor

When does proton pump inhibitor treatment become long term? A scoping review

Objective

Proton pump inhibitor (PPI) use has risen substantially, primarily driven by ongoing use over months to years. However, there is no consensus on how to define long-term PPI use. Our objectives were to review and compare definitions of long-term PPI use in existing literature and describe the rationale for each definition. Moreover, we aimed to suggest generally applicable definitions for research and clinical use.

Design

The databases PubMed and Cochrane Library were searched for publications concerning long-term use of PPIs and ClinicalTrials.gov was searched for registered studies. Two reviewers independently screened the titles, abstracts, and full texts in two series and subsequently extracted data.

Results

A total of 742 studies were identified, and 59 met the eligibility criteria. In addition, two ongoing studies were identified. The definition of long-term PPI use varied from >2 weeks to >7 years. The most common definition was ≥1 year or ≥6 months. A total of 12/61 (20%) of the studies rationalised their definition.

Conclusion

The definitions of long-term PPI treatment varied substantially between studies and were seldom rationalised.

In a clinical context, use of PPI for more than 8 weeks could be a reasonable definition of long-term use in patients with reflux symptoms and more than 4 weeks in patients with dyspepsia or peptic ulcer. For research purposes, 6 months could be a possible definition in pharmacoepidemiological studies, whereas studies of adverse effects may require a tailored definition depending on the necessary exposure time. We recommend to always rationalise the choice of definition.

Eight weeks of esomeprazole therapy reduces symptom relapse, compared with 4 weeks, in patients with Los Angeles grade A or B erosive esophagitis

BACKGROUND & AIMS

There is disagreement over the ideal duration of initial proton pump inhibitor (PPI) therapy for gastroesophageal reflux disease, and whether prolonged therapy increases healing of the esophagitis and prevents symptom relapse. We performed a multicenter, prospective, randomized, controlled study to compare the efficacies of 4 weeks vs 8 weeks of PPI therapy in reducing reflux symptoms and preventing symptom relapse in patients with Los Angeles grade A or B erosive esophagitis.

METHODS

Consecutive patients with symptomatic Los Angeles grade A or B erosive esophagitis were assigned randomly to groups given daily esomeprazole (40 mg) for 4 weeks (n = 207) or 8 weeks (n = 201) as their initial treatment. Patients with complete symptom resolution were switched to on-demand therapy until the end of week 20. All patients underwent follow-up endoscopy at the end of week 20. Symptom relapse was defined as 2 or more episodes of troublesome reflux symptoms per week or ingestion of PPI for more than 7 days within 4 weeks, owing to reflux symptoms.

RESULTS

The 4-week and 8-week groups had comparable rates of complete symptom resolution (77.9% vs 82.1%). However, the cumulative 12-week incidence of symptom relapse was higher for the 4-week group than for the 8-week group (62.5% vs 47.8%; difference, 14.7%; 95% confidence interval, 3.7%-25.7%; P = .009). No significant difference was observed between groups in the proportions of patients with sustained healing at the end of week 20 (49.6% vs 40.9%; P = .160).

CONCLUSIONS

Prolonging PPI therapy from 4 weeks to 8 weeks does not appear to increase the rate of complete symptom resolution in patients with mild erosive esophagitis. However, 8 weeks of PPI therapy reduces symptom relapse, compared with 4 weeks, in patients with Los Angeles grade A or B erosive esophagitis. ClinicalTrials.gov number: NCT01874535.