Effect of rabeprazole treatment on health-related quality of life and symptoms in patients with reflux esophagitis: a prospective multicenter observational study in Japan

Clinical efficacy of Yukgunja-tang combined with a proton pump inhibitor for refractory gastroesophageal reflux disease: study protocol for randomized, double-blind, double-dummy clinical trial

BACKGROUND

Yukgunja-tang (YGJ) is an herbal prescription used to treat the symptoms of gastroesophageal reflux disease (GERD). Although many preclinical and clinical studies on YGJ have been conducted on GERD, there is a lack of evidence from blinded studies to exclude placebo effects. Therefore, this protocol proposes a clinical trial that is single-centered, randomized, double-blinded, double-dummy to objectively evaluate the efficacy and safety of co-administered YGJ and rabeprazole (RPZ) in patients with GERD previously treated with proton pump inhibitors (PPIs) and still experiencing symptoms.

METHODS

A total of 86 participants with refractory GERD (rGERD) will be randomized in a 1:1 ratio to the treatment [YGJ and RPZ (10 mg/d)] and control groups [double-dose RPZ (20 mg/d)] for 4 weeks of treatment (weeks 0-4) followed by 4 weeks of follow-up (weeks 4-8). The Frequency Scale for the Symptoms of GERD will be analyzed for the primary endpoint. Reflux Disease Questionnaire, Reflux Symptom Score, GERD-Health Related Quality of Life, Overall Treatment Evaluation, Spleen Qi Deficiency Questionnaire, Damum Questionnaire, and dyspepsia Visual Analogue Scale will be used to evaluate treatment effects on GERD related symptoms and quality of life and to compare treatment effects by subgroups. Safety tests will be analyzed by investigating adverse events.

DISCUSSION

This clinical trial will be the first rigorous double-blind, double-dummy, placebo-controlled study to precisely evaluate the efficacy and safety of the combination of YGJ and PPIs in the treatment of rGERD. The results of this study will provide a reliable clinical basis for selecting botanical drug treatments for patients with rGERD.

TRIAL REGISTRATION

Clinical Research Information Service (registration number: KCT0008600, July 13, 2023, https://cris.nih.go.kr ).

Effects of coexisting upper gastrointestinal symptoms on daily life and quality of life in patients with gastroesophageal reflux disease symptoms

BACKGROUND AND AIM

Gastroesophageal reflux disease (GERD) is a common disease encountered in daily medical care and clinical problem which hampers daily life and reduces quality of life (QOL). The coexistence of GERD-related symptoms with the typical GERD symptoms, such as heartburn or acid regurgitation, and various upper abdominal symptoms is frequently observed in patients with GERD. However, the effect of these coexisting symptoms on the daily life and QOL of patients with GERD has not been clarified. Therefore, the effects of the various upper abdominal symptoms coexisting with GERD on the daily life and QOL of such patients were compared.

METHODS

A total of 113 newly diagnosed patients who visited our hospital with typical GERD symptoms were assessed using the modified frequency scale for the symptoms of GERD (MFSSG), gastroesophageal reflux and dyspepsia therapeutic efficacy and satisfaction test (GERD-TEST), and short-form 8-item health survey (SF-8) questionnaires. The "gastroesophageal reflux symptom" (7 items) and "dyspepsia symptom" (7 items) groups were divided into two "typical symptoms" and two "atypical symptoms" for a total of four categories. The Pearson's correlation coefficient and multiple regression analysis were used to evaluate the correlations between each symptom category and dissatisfaction for daily life [eating, sleeping, daily activities, mood, as well as dissatisfaction for daily life-symptom subscale (SS), which is the average of the four items in the GERD-TEST, the physical component summary [PCS] and mental component summary [MCS] of the SF-8, and the influence of each symptom category on the daily life and QOL.

RESULTS

The incidences of each symptom category in patients with GERD were high: typical GERD (100%), atypical GERD symptoms (67.3%), typical functional dyspepsia (FD) (71.7%), and atypical FD (75.2%). Pearson's correlation analysis demonstrated significant correlations between each symptom category and living status (dissatisfactions of eating, sleeping, daily activities, daily life-SS) and almost all items in SF-8 (PCS, MCS) (P < 0.05). Multiple regression analysis indicated the largest influences of each symptom category on living status and QOL in descending order: dissatisfaction for eating (atypical FD, typical FD), daily activities (atypical FD, typical FD, typical GERD), mood (atypical FD), daily life-SS (atypical FD, typical FD), PCS (typical FD), and MCS (atypical FD) (P < 0.05).

CONCLUSION

Coexisting FD symptoms, particularly atypical FD symptoms, had a large influence on the impairments of daily life and decreases in QOL. Daily medical care of GERD requires attention to coexisting symptoms and their treatment instead of just focusing on the chief complaints by patients.

Transabdominal ultrasound elastography of the esophagogastric junction predicts reflux esophagitis

PURPOSE

Abdominal ultrasound (US) can visualize the esophagogastric junction (EGJ) as a hyperechoic area in the dorsal portion of the lateral segment of the liver. We prospectively evaluated the EGJ using US elastography (US-EG) in patients with reflux esophagitis (RE) to examine prediction of distal esophageal function.

METHODS

Of 108 patients undergoing US-EG and esophagogastroduodenoscopy, 102 in whom the EGJ was observed for ≥ 15 s were included. The subjects were divided into a RE group (n = 41, Grade M/A/B:24/13/4 according to modified Los Angeles Classification) and a non-RE group (n = 61). Direct strain elastography (LOGIQ E9, GE Healthcare), which gives a semi-quantitative elasticity index within a region of interest including the lateral segment, was used as a standard for measurement of the change in stiffness (CS) at the EGJ.

RESULTS

The number of CS as determined by US-EG was 6.0 (5.5-6.7) in the RE group and 8.6 (6.6-10.0) in the non-RE group (P < 0.0001). In ROC analysis, the AUC was 0.8415 for diagnosis of RE using the number of CS. At a cut-off of 7.7, the sensitivity, specificity, and accuracy for diagnosis were 92.7, 65.6, and 74.5%, respectively.

CONCLUSION

The presence of RE can be predicted based on US-EG.

Therapeutic Response to Twice-daily Rabeprazole on Health-related Quality of Life and Symptoms in Patients with Refractory Reflux Esophagitis: A Multicenter Observational Study

Objective To investigate the effect of twice-daily rabeprazole doses on health-related quality of life in refractory patients. Methods and Patients Reflux esophagitis patients with an insufficient response to once-daily proton pump inhibitor therapy (Los Angeles Classification grade A-D) received rabeprazole 10 mg or 20 mg twice daily for 8 weeks. The health-related quality of life (SF-8™) and symptoms, using the Frequency Scale for the Symptoms of Gastroesophageal reflux disease, were evaluated before treatment and at weeks 4 and 8. Endoscopy was performed at baseline and at weeks 8 and 32 where possible. The rabeprazole dose was determined by the attending physician. Results There were 1,796 patients analyzed for the efficacy of the twice-daily treatment. Of these cases, 1,462 were treated with rabeprazole 10 mg twice daily, and 334 were treated with rabeprazole 20 mg twice daily. The factors that affected the selection of the twice-daily rabeprazole dose by physicians were evaluated, and as expected, "endoscopic findings when treatment was started" had a strong effect on the selection of the rabeprazole dose. With both regimens, health-related quality of life and subjective symptoms were significantly improved at weeks 4 and 8 compared to baseline (p<0.001). The recurrence rate of erosive esophagitis at week 32 was 9.7% in rabeprazole twice daily-treated patients and 28.4% in proton pump inhibitor (PPI) once daily-treated patients. Both regimens were well tolerated. Conclusion Twice-daily treatment with rabeprazole improved the subjective symptoms and health-related quality of life in patients with refractory reflux esophagitis more effectively than the standard once-daily dose.

Gastroesophageal reflux disease-related and functional heartburn: pathophysiology and treatment

PURPOSE OF REVIEW

Patients who continue to experience heartburn symptoms despite adequate-dose proton pump inhibitor therapy have unmet clinical needs. In this review, we focus on the most recent findings related to the mechanism of heartburn symptom generation, and on the treatment of gastroesophageal reflux disease-related and functional heartburn.

RECENT FINDINGS

The immunological mechanism in the esophageal mucosa has been addressed as a potential mechanism of the onset of esophageal mucosa damage and the generation of heartburn symptoms. Peripheral or central hypersensitivity in viscera is a potentially unifying pathophysiological concept in functional heartburn. Vonoprazan, a novel and potent first-in-class potassium-competitive acid blocker, is expected to prove useful in the treatment of reflux disease.

SUMMARY

New findings in the mechanisms of heartburn symptom generation are emerging, including the immunological mediation of esophageal mucosal damage and the development of visceral hypersensitivity in functional heartburn. In the future, we anticipate the emergence of new and specific therapeutic options based on these mechanisms, with less dependence on acid-suppressing agents.

Persistent reflux symptoms cause anxiety, depression, and mental health and sleep disorders in gastroesophageal reflux disease patients

Some patients with gastroesophageal reflux disease experience persistent reflux symptoms despite proton pump inhibitor therapy. These symptoms reduce their health-related quality of life. Our aims were to evaluate the relationship between proton pump inhibitor efficacy and health-related quality of life and to evaluate predictive factors affecting treatment response in Japanese patients. Using the gastroesophageal reflux disease questionnaire, 145 gastroesophageal reflux disease patients undergoing proton pump inhibitor therapy were evaluated and classified as responders or partial-responders. Their health-related quality of life was then evaluated using the 8-item Short Form Health Survey, the Pittsburgh Sleep Quality Index, and the Hospital Anxiety and Depression Scale questionnaires. Sixty-nine patients (47.6%) were partial responders. These patients had significantly lower scores than responders in 5/8 subscales and in the mental health component summary of the 8-item Short Form Health Survey. Partial responders had significantly higher Pittsburgh Sleep Quality Index and Hospital Anxiety and Depression Scale scores, including anxiety and depression scores, than those of responders. Non-erosive reflux disease and double proton pump inhibitor doses were predictive factors of partial responders. Persistent reflux symptoms, despite proton pump inhibitor therapy, caused mental health disorders, sleep disorders, and psychological distress in Japanese gastroesophageal reflux disease patients.

[Inadequate response to proton pump inhibitor therapy: causes and patient management tactics]

The past decade has been marked by a considerable increase in the number of patients with gastroesophageal reflux disease and gastroduodenal ulcer who show an inadequate response to proton pump inhibitor (PPI) therapy. At the present time, most of the causes diminishing the response have been elucidated. Unfortunately, they cannot always be eliminated by drug therapy; nonetheless, rabeprazole has a number of advantages over other PPIs. The major causes of an inadequate response to PPI therapy are low treatment motivation; nocturnal gastric acid breakthroughs; genetically determined CYP polymorphism; chiefly nighttime symptoms of gastroesophageal reflux disease; non-acid refluxes; hypersensitive esophagus; overweight and obesity.

Randomized controlled trial comparing the efficacy of mosapride plus omeprazole combination therapy to omeprazole monotherapy in gastroesophageal reflux disease

OBJECTIVE

We investigated whether the prokinetic activity of mosapride, a 5-hydroxytryptamine 4 receptor agonist, in combination with proton pump inhibitor (PPI) would ameliorate symptoms of gastroesophageal reflux disease (GERD) in Japanese patients.

METHODS

Patients who experienced reflux symptoms more than twice weekly were eligible for this study. In all, 60 patients were randomized to receive mosapride 5 mg thrice daily combined with omeprazole 10 mg once daily (GO group), or omeprazole alone (O group) for 4 weeks. The patients completed the frequency scale for the symptoms of GERD (FSSG) at the beginning and the end of the study. The primary outcome compared changes in the FSSG reflux-related symptom (RS) score between treatment groups during the study period.

RESULTS

The FSSG RS scores significantly decreased both in the GO group and the O group, with no differences in improvement between the groups (-5.86 for the GO group vs -4.89 for the O group, P = 0.49). In non-erosive reflux disease (NERD) patients the improvement was significantly lower than that in erosive GERD patients (-4.00 vs -7.67, P = 0.02). However, the addition of mosapride was effective in subgroup analyses of specific symptoms, such as burping.

CONCLUSIONS

Combining mosapride with PPI provided no additional amelioration of reflux symptoms compared to PPI alone. Both regimens provided less relief from reflux symptoms in NERD than in erosive GERD patients. The addition of mosapride ameliorated reflux in patients with symptoms like burping.

Categorization of upper gastrointestinal symptoms is useful in predicting background factors and studying effects and usages of digestive drugs

BACKGROUND

There have been very few reports assessing the relationship between various upper gastrointestinal (GI) symptoms or evaluating each individual upper GI symptom separately.

METHODS

Based on the answers to Frequency Scale for the Symptoms of GERD from a large-scale population of healthy adults in Japan, a hierarchical cluster analysis was performed to categorize the typical 12 upper GI symptoms. The associations between the 12 symptoms and 13 background factors were systematically analyzed among the 18,097 digestive drug-free subjects, 364 proton-pump inhibitor (PPI) users, and 528 histamine H₂-receptor antagonist (H₂RA) users.

RESULTS

The derived relationship between the 12 upper GI symptoms suggests the five symptom categories: heartburn (2), dyspepsia (4), acid regurgitation (3), pharyngo-upper esophageal discomfort (2), and fullness while eating (1). Among the digestive drug-free subjects, inadequate sleep, weight gain in adulthood, NSAID use, meals immediately prior to sleep, and frequent skipping of breakfast showed significant positive association with most upper GI symptoms. Compared to the digestive drug-free subjects, significantly associated factors for PPI and H₂RA users are respectively different in "4 of 5" and "5 of 5" symptoms in heartburn and acid regurgitation categories, "1 of 2" and "1 of 2" symptoms in pharyngo-upper esophageal discomfort category, and "0 of 5" and "3 of 5" symptoms in dyspepsia and fullness while eating categories. These differences between digestive drug-free subjects and gastric acid suppressant users seem to correlate with our experiences in clinical situations: heartburn and acid regurgitation category symptoms are effectively controlled with PPI and H₂RA whereas other category symptoms are not.

CONCLUSIONS

The 12 upper GI symptoms can be classified into five categories, which are statistically associated with various background factors. The differences of associated factors between digestive drug-free subjects and digestive drug users may be useful in studying the drug effects upon diverse upper GI symptoms.

Response to gastroesophageal reflux disease therapy: assessment at 4 weeks predicts response/non-response at 8 weeks

BACKGROUND

Many questionnaires that assess subjective symptoms or health-related quality of life (HRQOL) have been developed to confirm the efficacy of treatment in patients with gastroesophageal reflux disease (GERD). However, few reports have correlated early improvements in scale scores with predictions of subsequent therapeutic responses. Our aim was to investigate the appropriate timing for evaluating therapeutic response and subsequent changes in symptoms and HRQOL.

METHODS

This was a post hoc analysis of a multicenter prospective cohort study. A total of 5,279 GERD patients with Frequency Scale for the Symptoms of GERD (FSSG) scores ≥ 8 points at baseline were analyzed. Correlations between HRQOL and FSSG were investigated and logistic regression analysis was performed.

RESULTS

The FSSG scores and HRQOL improvements in responders were significantly greater than in non-responders. Positive correlation between FSSG and HRQOL was observed. Based on the analysis, severity of esophagitis at baseline, complications of hypertension, higher HRQOL mental score at baseline, and higher FSSG score at baseline were predictors of responders. Gastrectomy, complication of insomnia, and prior medication with proton pump inhibitors were predictors of non-responders.

CONCLUSION

Evaluating patients' symptoms during the fourth week of rabeprazole therapy allows predictions of subsequent changes in subjective symptoms and HRQOL.

Clinical symptoms of FSSG in gastroesophageal reflux disease are critical for PPI treatment: Japanese multi-centers with 185 patients

AIM

The main aim of this study was to determine whether questionnaire evaluations of clinical symptoms in gastroesophageal reflux disease were useful to assess proton pump inhibitor therapy.

METHODS

A total of 185 Japanese patients (men, 88; women, 97; age: 55.7 ± 16.1 years) with gastroesophageal reflux disease were enrolled. The patients were divided based on the frequency scale for symptoms of gastroesophageal reflux disease: severe symptoms with scores ≥8 and mild symptoms with scores ≤7. Quality of life was evaluated with the Medical Outcomes Study 8-Item Short-Form Health Survey. All patients were treated with a proton pump inhibitor, rabeprazole (10 mg/day), for 8 weeks.

RESULTS

Patients were classified into four groups: reflux esophagitis with severe symptoms (n = 92, 49.7%); reflux esophagitis with mild symptoms (n = 17, 9.2%); non-erosive reflux disease with severe symptoms (n = 66, 35.7%); and non-erosive reflux disease with mild symptoms (n = 10, 5.4%). The dysmotility score was high in non-erosive reflux disease with severe symptoms compared with reflux esophagitis with severe symptoms (9.1 ± 0.5 vs 6.8 ± 0.5, P < 0.05). The symptom score and quality of life in the severe symptoms groups for both reflux esophagitis and non-erosive reflux disease were significantly improved by rabeprazole treatment. Only the reflux score was improved by rabeprazole in the reflux esophagitis with mild symptoms group; no therapeutic effect was observed for the non-erosive reflux disease with mild symptoms group.

CONCLUSIONS

Low scores on the frequency scale for the symptoms of gastroesophageal reflux disease indicate poor responsiveness to proton pump inhibitor treatment, and high scores indicate good responsiveness.

Development and evaluation of a modified Frequency Scale for the Symptoms of Gastroesophageal Reflux Disease to distinguish functional dyspepsia from non-erosive reflux disease

BACKGROUND AND AIM

The Frequency Scale for the Symptoms of Gastroesophageal Reflux Disease (FSSG) is the standard questionnaire used in Japan for the diagnosis of gastroesophageal reflux disease (GERD) and assessment of the response to treatment. We modified the FSSG in order to assess dyspepsia symptoms, and evaluated the modified questionnaire.

METHODS

We modified the FSSG by adding two questions on interdigestive and postprandial epigastric pain. We then assessed the modified FSSG with 100 new untreated symptomatic patients presenting to hospital and in 200 subjects undergoing health checks. Endoscopic assessment of the esophagogastric junction was performed according to the modified Los Angeles classification with addition of Grade N (normal appearance) and Grade M (minimal change). Endoscopic images were assessed by five experienced endoscopists blinded to the questionnaire results.

RESULTS

The 100 new patients included 16 with erosive GERD (>Grade A), 12 with peptic ulcer, and two with gastric cancer. Among the 70 patients with no evidence of organic disease, the modified FSSG diagnosed functional dyspepsia (FD) in 41 and non-erosive gastric disease (NERD) in 29. A significant difference was seen in the dyspepsia score between patients with FD and NERD. Subjects with endoscopic GERD undergoing health checks had significantly higher scores for all symptoms, reflux symptoms, and dyspeptic symptoms on the modified FSSG.

CONCLUSION

The modified FSSG can clearly distinguish FD from NERD, and is useful for the assessment of dyspeptic symptoms.

Symptoms and quality of life in underweight gastroesophageal reflux disease patients and therapeutic responses to proton pump inhibitors

BACKGROUND AND AIM

A correlation to obesity has been reported in patients with gastroesophageal reflux disease (GERD). However, insufficient data have been obtained regarding underweight GERD patients. Post hoc analysis of a multicenter prospective cohort study was conducted to evaluate subjective symptoms and health-related quality of life (HRQOL) in underweight GERD patients (body mass index [BMI] < 18.5) and to evaluate therapeutic response to proton pump inhibitors.

METHODS

A total of 2646 patients who underwent endoscopy were classified by BMI and analyzed. Rabeprazole was administered for 8 weeks. Subjective symptoms and HRQOL were assessed using questionnaires (F-Scale and SF-8™).

RESULTS

Baseline endoscopy revealed 29.2% of patients had non-erosive reflux disease (NERD). Underweight status was identified in 5.8% of GERD patients, and mean baseline symptoms score and SF-8 physical component summary (PCS) score were 18.6 and 42.4, respectively, reflecting greater impairment compared with the values of 15.4 and 45.6 in normal-weight patients (BMI ≥ 22 but < 25). Treatment with rabeprazole resulted in a decrease from 18.6 at baseline to 6.7 at week 8 in underweight reflux esophagitis subjects, and from 15.0 to 6.3 in underweight NERD patients. PCS score improved in underweight patients. These changes were about the same as in normal-weight or obese patients.

CONCLUSIONS

Japanese GERD patients are often obese, as reported previously, but some GERD patients are underweight. Baseline symptoms and QOL in underweight GERD patients tended to be more severe than in normal-weight patients, but therapeutic response with proton pump inhibitors was about the same as in normal-weight or obese patients.

Combination of angiotensin II receptor blockers promotes proton pump inhibitor-based healing of reflux esophagitis

BACKGROUND

Several studies have described factors associated with the failure of proton pump inhibitors (PPIs) to effect endoscopic healing of reflux esophagitis (RE), but few studies have addressed factors promoting PPI-based endoscopic healing. We performed post hoc analysis of a multicenter prospective cohort of RE patients to identify factors encouraging endoscopic healing of this disorder.

METHODS

Patients with RE received 10 or 20 mg rabeprazole for 8 weeks, and endoscopic findings before and after treatment were studied. To evaluate the effects of patient background factors on endoscopic healing, we performed multiple logistic regression analysis and determined the respective odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

A total of 454 patients who underwent endoscopy at baseline and again at week 8 were included in the analysis. After 8 weeks of treatment, improvement in endoscopic findings was observed in 94.1% (427/454) of patients, and endoscopic healing was seen in 76.7% (348/454). Multiple logistic regression analysis revealed that a combination of angiotensin II receptor blockers (ARBs) had a significant positive impact on endoscopic healing (OR 3.9, 95% CI 1.411-10.903), but no significant positive relationship was seen for other concomitant drugs such as nonsteroidal anti-inflammatory drugs and calcium channel blockers. Severe RE at baseline (OR 0.365, 95% CI 0.281-0.475) and PPI therapy prior to enrollment (OR 0.154, 95% CI 0.052-0.453) were found to have significant negative effects on endoscopic healing.

CONCLUSIONS

Concomitant use of ARBs may promote endoscopic healing of RE treated with PPIs.

Correlation between symptomatic improvement and quality of life in patients with reflux and dyspeptic symptoms

We investigated the correlation between symptomatic improvement and quality of life in Japanese gastroesophageal reflux disease patients with PPI. Eighty one patients with reflux and dyspeptic symptom were enrolled. The evaluation of the symptom was used he Frequency Scale for the Symptom of GERD in 3 categories: total score of 12 questions, score related to reflux symptoms, and score related to dyspeptic symptoms and the evaluation of the quality of life was use the 8-item Short Form Health Survey in 2 categories, the physical component summary score and mental component summary score. All patients administered rabeprazole 10 mg/day for 8 weeks. We investigated the correlation between symptomatic improvement with proton pump inhibitor and quality of life. Significant symptomatic improvement was seen in the total score of 12 questions (26.7 ± 8.8 → 17.5 ± 5.9, p<0.0001), score related to reflux symptoms (14.9 ± 5.4 → 9.6 ± 3.6, p<0.0001), and score related to dyspeptic symptoms (11.8 ± 4.3 → 8.0 ± 2.9, p<0.0001). Significant improvement in quality of life was seen in the physical component summary score (47.8 ± 6.6 → 50.0 ± 5.9, p = 0.0209) and mental component summary score (47.4 ± 8.5 → 50.4 ± 5.3, p = 0.0133) with proton pump inhibitor. With proton pump inhibitor, a significant positive correlation was seen between the improvement rates in total score of 12 questions, score related to dyspeptic symptoms and in mental component summary score at 8 weeks (total score of 12 questions: r = 0.275, p = 0.0265, score related to dyspeptic symptoms: r = 0.367, p = 0.0027). In conclusion, quality of life was associated with improvement in dyspeptic symptoms with proton pump inhibitor treatment.