Esomeprazole tablet vs omeprazole capsule in treating erosive esophagitis

Vonoprazan versus proton-pump inhibitors for healing gastroesophageal reflux disease: A systematic review

BACKGROUND AND AIM

Gastroesophageal reflux disease (GERD) is a common disease caused by reflux of gastric contents to the esophagus. Proton-pump inhibitors (PPIs) are recommended as a first-line therapy to treat GERD. Recently, a new potassium-competitive acid blocker, vonoprazan, was launched in Japan. We aimed to evaluate the comparative efficacy of vonoprazan and other PPIs in healing GERD.

METHODS

We used MEDLINE and the Cochrane Central Register of Controlled Trials to search the literature. Double-blind randomized controlled trials for PPIs and/or vonoprazan that were published in English or Japanese and assessed healing effects in adult GERD patients were included. To estimate the comparative efficacy of treatments, we performed a Bayesian network meta-analysis to assess the consistency assumption.

RESULTS

Of 4001 articles identified in the database, 42 studies were eligible. One study was hand-searched and added to the analysis. For the main analysis of healing effects at 8 weeks, odds ratios (ORs) of vonoprazan (20 mg daily) to esomeprazole (20 mg), rabeprazole (20 mg), lansoprazole (30 mg), and omeprazole (20 mg) were 2.29 (95% credible interval, 0.79-7.06), 3.94 (1.15-14.03), 2.40 (0.90-6.77), and 2.71 (0.98-7.90), respectively. Subgroup analysis for patients with severe esophagitis at baseline showed significantly higher ORs for vonoprazan versus most of the comparator PPIs.

CONCLUSIONS

This analysis shows that the GERD healing effect of vonoprazan is higher than that of rabeprazole (20 mg) but not higher than other PPIs. Subgroup analysis indicated that vonoprazan is more effective than most PPIs for patients with severe erosive esophagitis.

Meta-analysis of the effectiveness of esomeprazole in gastroesophageal reflux disease and Helicobacter pylori infection

WHAT IS KNOWN AND OBJECTIVE

Proton pump inhibitors (PPIs) are one of the most widely used classes of drugs. However, the quantum clinical benefit of newer and more expensive PPIs over the older generation PPIs remains uncertain. This meta-analysis sought to assess the clinical and safety profiles of esomeprazole versus omeprazole at pharmacologically equivalent doses in healing gastroesophageal reflux disease (GERD), peptic ulcer disease and eradicating Helicobacter pylori (H. pylori) infection.

METHODS

PubMed and the Cochrane Library were searched for randomized controlled trials comparing esomeprazole with omeprazole at all doses up to February 2015. Trials were assessed by two reviewers for eligibility according to predefined study inclusion criteria. Meta-analysis was conducted using a random effects model, and heterogeneity in the estimated effects was investigated using meta-regression. Sensitivity analysis was performed to test the robustness of the findings.

RESULTS AND DISCUSSION

Fifteen trials were included and none of which compared esomeprazole with omeprazole in peptic ulcer disease. The included studies had not evaluated esomeprazole 20 mg versus omeprazole 40 mg. In GERD, esomeprazole 40 mg (relative risk (RR) = 1·07; 95% confidence interval (CI) 1·02 to 1·12) and 20 mg (RR=1·04; 95% CI 1·01 to 1·08) significantly improved esophagitis healing when compared with omeprazole 20 mg at week 8. The corresponding numbers needed to treat were 17 and 30, respectively. No significant difference was observed between esomeprazole 20 mg and omeprazole 20 mg at week 4. In H. pylori eradication, there was no difference in the treatment effects between esomeprazole 20 mg and omeprazole 20 mg (RR = 1·01;95% CI 0·96 to 1·05). Their safety profiles were comparable.

WHAT IS NEW AND CONCLUSION

Esomeprazole demonstrated better esophagitis healing rate in patients with GERD than omeprazole at week 8. However, this clinical advantage diminished when both drugs were given at the same doses at week 4. Superiority of esomeprazole was not observed in the H. pylori eradication rates.

Science at the Crossroads: Fact or Fiction?

Modern Academic Science is largely based on the formulation of hypotheses that are then confirmed through observations and experiments. There is little scope forcuriositythat played an important role in early Science. Results carrying negative implications are not easy to publish, and hypotheses have a tendency to take on the mantra of religious beliefs. Academic Science is facing on many fronts pressures that hardly existed in the past. Financial rewards apart from salary can be very high, in the form of fees for consultants, expert legal witnesses, patent development, and even the establishment of private companies. Commercial funding forms a significant percentage of the Total Research Budgets in Science and Medicine, but this often leads to loss of control over research protocols and freedom to communicate the results. Media attention confers fame and prestige that is assiduously sought out by some individual scientists, often supported by University resources, and Press Conferences prior to or synchronous with actual publication. Scientists have long been employed full-time by Government Departments, but research contracts are being increasingly offered by the latter to academic staff on a part-time basis. These pressures and opportunities, together with the priority given to research by most University Tenure and Promotion Committees, are tending to diminish the appetite of scientists for other important responsibilities such as teaching and administration. In a few decades, University scientists have moved from the »Ivory Tower« to the High Street, and many are serving more than one master. The above scenario may bring increased remuneration and the pursuit of research that would be too expensive without these external sources, but adverse consequences have also occurred. They may lead to the complicity of scientists, through no fault of their own, in the introduction of drugs and supplements that: a) fail to deliver the benefits claimed; b) increase the risk of some unrelated illness; c) possess dangerous side effects not known or reported at the time of introduction. Examples include hormone replacement therapy and antioxidant vitamins (A and E) to protect against Coronary Heart Disease; dietary fibre to prevent colon cancer; and arguably calcium supplements to treat osteoporosis. On occasions, academic scientists have served as fronts for the publication by the manufacturers of falsified reports minimizing the risk of serious drug side-effects to ensure Regulatory Approval, as occurred with Vioxx in the treatment of arthritis, and Seroquel for schizophrenia and bipolar depression. Individual fraud or misconduct is more frequent than suspected, because most incidents are without major impact and are suppressed by Universities and Funding Agencies. Major scandals are rare, but may have serious repercussions for the general public and bring science into disrepute. Recent examples include: the Cold Fusion controversy (Low Energy Nuclear Reaction); the link age by Andrew Wakefield of autism with Rubella vaccination; the infamous creation of stem cells by somatic cell nuclear transfer falsely reported by Hwang Woo-Suk. Fraud by commercial companies is subject to the full force of the law, but Science is treated as a self-regulating profession, and as such the punishments handed out are relatively trivial. In essence, Science prior to 1950, except in North America, proceeded along a highway that segregated the traffic into Commercial, Government and Academic streams, and passed through inspiring landscapes and green pastures. It later came to a crossroads from which the alternative road led to the Marketplace, and on which segregation into the above three streams was not enforced. It has now become the main thoroughfare for Science world-wide, but there are reasons to believe that this has increased the incidence of dangerous driving and traffic accidents in the form of conflicts of interest, unethical behaviour, misconduct and even fraud. It may be too late to return to the crossroads and continue along the original highway, but there could be considerable merit in restoring the original segregation between the three streams of Science and in developing, as well as enforcing, a stricter code of behaviour, for which some elements are proposed.

Impact of oesophagitis classification in evaluating healing of erosive oesophagitis after therapy with proton pump inhibitors: a pooled analysis

BACKGROUND AND AIMS

The results of clinical trials with proton pump inhibitors (PPIs) are usually based on the Hetzel-Dent (HD), Savary-Miller (SM), or Los Angeles (LA) classifications to describe the severity and assess the healing of erosive oesophagitis. However, it is not known whether these classifications are comparable. The aim of this study was to review systematically the literature to compare the healing rates of erosive oesophagitis with PPIs in clinical trials assessed by the HD, SM, or LA classifications.

METHODS

A recursive, English language literature search in PubMed and Cochrane databases to December 2006 was performed. Double-blind randomized control trials comparing a PPI with another PPI, an H2-RA or placebo using endoscopic assessment of the healing of oesophagitis by the HD, SM or LA, or their modified classifications at 4 or 8 weeks, were included in the study. The healing rates on treatment with the same PPI(s), and same endoscopic grade(s) were pooled and compared between different classifications using Fisher's exact test or chi2 test where appropriate.

RESULTS

Forty-seven studies from 965 potential citations met inclusion criteria. Seventy-eight PPI arms were identified, with 27 using HD, 29 using SM, and 22 using LA for five marketed PPIs. There was insufficient data for rabeprazole and esomeprazole (week 4 only) to compare because they were evaluated by only one classification. When data from all PPIs were pooled, regardless of baseline oesophagitis grades, the LA healing rate was significantly higher than SM and HD at both 4 and 8 weeks (74, 71, and 68% at 4 weeks and 89, 84, and 83% at 8 weeks, respectively). The distribution of different grades in study population was available only for pantoprazole where it was not significantly different between LA and SM subgroups. When analyzing data for PPI and dose, the LA classification showed a higher healing rate for omeprazole 20 mg/day and pantoprazole 40 mg/day (significant at 8 weeks), whereas healing by SM classification was significantly higher for omeprazole 40 mg/day (no data for LA) and lansoprazole 30 mg/day at 4 and 8 weeks. The healing rate by individual oesophagitis grade was not always available or robust enough for meaningful analysis. However, a difference between classifications remained.

CONCLUSION

There is a significant, but not always consistent, difference in oesophagitis healing rates with the same PPI(s) reported by the LA, SM, or HD classifications. The possible difference between grading classifications should be considered when interpreting or comparing healing rates for oesophagitis from different studies.

GORD in adults

INTRODUCTION

Up to 25% of people have symptoms of gastro-oesophageal reflux disease (GORD), but only 25-40% of these have oesophagitis visible on endoscopy. About 80% of people with GORD will have recurrent symptoms if treatment is stopped, and severe oesophagitis may result in oesophageal stricture or Barrett's oesophagus.

METHODS AND OUTCOMES

We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of initial treatment of GORD associated with oesophagitis? What are the effects of maintenance treatment of GORD associated with oesophagitis? We searched: Medline, Embase, The Cochrane Library, and other important databases up to July 2007 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations, such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

RESULTS

We found 29 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

CONCLUSIONS

In this systematic review, we present information relating to the effectiveness and safety of the following interventions: antacids/alginates, H(2) receptor antagonists, laparoscopic surgery, lifestyle advice/modification, motility stimulants, open surgery, and proton pump inhibitors.

Comparison of esomeprazole enteric-coated capsules vs esomeprazole magnesium in the treatment of active duodenal ulcer: A randomized, double-blind, controlled study

AIM: To evaluate the efficacy and tolerability of two different preparations of esomeprazole in healing duodenal ulcers.

METHODS: A total of 60 patients with active duodenal ulcers were enrolled and randomized to receive esomeprazole enteric-coated capsules (40 mg) or esomeprazole magnesium (40 mg), once daily, for 4 consecutive wk, with ulcer healing being monitored by endoscopy. Safety and tolerability were also assessed.

RESULTS: Fifty seven patients completed the whole trial. The ulcer healing rates at the end of wk 2 were 86.7% and 85.2% in the esomeprazole enteric-coated capsules and esomeprazole magnesium groups, respectively (P = 0.8410), and reached 100% at the end of wk 4 in both groups. Symptom relief at the end of wk 2 was 90.8% in the esomeprazole enteric-coated capsules group and 86.7% in the esomeprazole magnesium group (P = 0.5406); at the end of wk 4 symptom relief was 95.2% and 93.2%, respectively (P = 0.5786). Adverse events occurred in 16.7% of the esomeprazole enteric-coated capsules group and 14.8% of the esomeprazole magnesium group (P = 1.0000).

CONCLUSION: The efficacies of esomeprazole enteric-coated capsules and esomeprazole magnesium in healing duodenal ulcer lesions and relieving gastrointestinal symptoms are equivalent. The tolerability and safety of both drugs were comparable.

Effect of esomeprazole on symptom relief and improvement of quality of life in gastroesophageal reflux disease patients

AIM: To compare the efficacy and safety of esomeprazole with omeprazole on symptom relief and improvement of quality of life in gastroesophageal reflux disease (GERD) patients.

METHODS: A prospective, randomized controlled study was designed. A total of 78 GERD patients diagnosed with endoscope and/or their 24 h esophageal pH monitored were randomized into esomeprazole treatment group and omeprazole treatment group (39 patients each group). Patients in the two groups received standard doses of esomeprazole (20 mg, twice a day, po) or double doses of omeprazole (20 mg, twice a day, po) for 8 wk. Symptom relief, efficiency, cure rate and quality of life were compared between the two groups.

RESULTS: Seven-six patients completed the 8-week therapy. One patient in each group was dropped out because of running counter to the RE testing procedure. Symptoms of the two groups at weeks 4 and 8 were significantly improved. Symptoms of patients in the esomeprazole group were much better improved than those in the omeprazole group (P < 0.01). There was a significant difference in remission of heartburn and chest pain between the two groups (78.3% vs 45.5%, 64.3% vs 37.5%, P < 0.05). However, there was no significant difference in remission of acid regurgitation and dysphagia between the two groups. There was a significant difference in the efficiency and cure rate at weeks 4 and 8 between the two groups (4 wk: 88.8% vs 59.3%, 80.0% vs 51.9%, P < 0.05; 8 wk: 96.0% vs 70.4%, 88.0% vs 63.1%, P < 0.05). The quality of life, cure rate, vitality (VT) and social function (SF) were much better improved in the esomeprazole group than in the omeprazole group (92.5 ± 5.7 vs 85.3 ± 7.1, 85.2 ± 4.6 vs 76.8 ± 6.5, P < 0.05).

CONCLUSION: Standard doses of esomeprazole have better effects on improving heartburn and chest pain, cure rate, VT and SF in GERD patients than double doses of omeprazole.

Rational prescription of drugs within similar therapeutic or structural class for gastrointestinal disease treatment: Drug metabolism and its related interactions

AIM: To review and summarize drug metabolism and its related interactions in prescribing drugs within the similar therapeutic or structural class for gastrointestinal disease treatment so as to promote rational use of medicines in clinical practice.

METHODS: Relevant literature was identified by performing MEDLINE/Pubmed searches covering the period from 1988 to 2006.

RESULTS: Seven classes of drugs were chosen, including gastric proton pump inhibitors, histamine H₂-receptor antagonists, benzamide-type gastroprokinetic agents, selective 5-HT₃ receptor antagonists, fluoroquinolones, macrolide antibiotics and azole antifungals. They showed significant differences in metabolic profile (i.e., the fraction of drug metabolized by cytochrome P450 (CYP), CYP reaction phenotype, impact of CYP genotype on interindividual pharmacokinetics variability and CYP-mediated drug-drug interaction potential). Many events of severe adverse drug reactions and treatment failures were closely related to the ignorance of the above issues.

CONCLUSION: Clinicians should acquaint themselves with what kind of drug has less interpatient variability in clearance and whether to perform CYP genotyping prior to initiation of therapy. The relevant CYP knowledge helps clinicians to enhance the management of patients with gastrointestinal disease who may require treatment with polytherapeutic regimens.

The role of proton pump inhibitors in the treatment of Zollinger-Ellison syndrome

Zollinger-Ellison syndrome is characterised by refractory peptic ulcer disease, diarrhoea and gastric acid hypersecretion associated with a gastrin-secreting tumour. The incidence is unknown, but, in the US, the frequency is 0.1-3.0 million people. Zollinger-Ellison syndrome is associated with multiple endocrine neoplasia type 1 in 25-35% of the cases. The diagnosis of Zollinger-Ellison syndrome is suggested when plasma gastrin is > 1000 pg/ml and the basal acid output is > 15 mEq/h or when associated with a pH < 2. The treatment is focused on controlling gastric acid hypersecretion and localisation of the tumour and its metastases. Proton pump inhibitors are the most effective antisecretory drugs and can be administered at high dosages. This review focuses on the role of the proton pump inhibitors in the management of gastric acid hypersecretion in Zollinger-Ellison syndrome.