Comparing omeprazole with fluoxetine for treatment of patients with heartburn and normal endoscopy who failed once daily proton pump inhibitors: double-blind placebo-controlled trial

BACKGROUND

Patients with heartburn but without esophageal erosion respond less well to proton pump inhibitors (PPIs). There is a growing body of evidence implicating the role of psychological comorbidities in producing reflux symptoms. Pain modulators improve symptoms in patients with other functional gastrointestinal disorders. We aimed to compare the efficacy of fluoxetine with omeprazole and placebo to achieve symptomatic relief in patients with heartburn and normal endoscopy who failed once daily PPIs.

METHODS

Endoscopy-negative patients with heartburn who failed once daily PPIs were randomly allocated to receive 6 weeks treatment of fluoxetine, omeprazole, or placebo. Random allocation was stratified according to ambulatory pH monitoring study. Percentage of heartburn-free days and symptom severity was assessed.

KEY RESULTS

Sixty patients with abnormal and 84 patients with normal pH test were randomized. Subjects receiving fluoxetine experienced more improvement in percentage of heartburn-free days (median 35.7, IQR 21.4-57.1) than those on omeprazole (median 7.14, IQR 0-50, p < 0.001) or placebo (median 7.14, IQR 0-33.6, p < 0.001). In normal pH subgroup, fluoxetine was superior to both omeprazole and placebo regarding percentage of heartburn-free days (median improvement, 57.1, IQR 35.7-57.1 vs 13.9, IQR, 0-45.6 and 7.14, 0-23.8, respectively, p < 0.001), but no significant difference was observed between medications in abnormal pH subgroup.

CONCLUSIONS & INFERENCES

Fluoxetine was superior to omeprazole for improving the symptoms of patients with heartburn and normal endoscopy who failed once daily PPIs. The superiority of fluoxetine was mostly attributed to those with normal esophageal pH rather than those with abnormal pH (ClinicalTrials.gov, number NCT01269788).

Prognostic role of Helicobacter pylori infection in acute coronary syndrome: a prospective cohort study

Abstract

In a prospective cohort study, we evaluated the effect of Helicobacter pylori seropositivity on the risk of future adverse cardiovascular outcomes among patients with acute coronary syndrome (ACS). In 433 patients, IgA and IgG antibodies to H pylori, along with classic risk factors, including hypertension, diabetes, hyperlipidaemia, smoking and family history of coronary artery disease (CAD) were determined. Short-and long-term follow-up information on adverse outcomes, defined as recurrence of unstable angina, myocardial infarction, coronary angioplasty, coronary artery bypass graft surgery, and sudden cardiac death was obtained. None of the classic CAD risk factors correlated with incidence of either short- or long-term outcomes. Seropositivity for H pylori was significantly associated with risk of short-term adverse outcomes, and independently predicted their incidence in multivariate regression (R = 3.05, p < 0.001). Results failed to show such an association between H pylori seropositivity and long-term adverse outcomes. H pylori infection may affect short-term prognosis in patients with ACS. Randomised trials are needed to evaluate the role of H pylori eradication in these patients.