Prevalence and risk factors for gastroesophageal reflux disease in the Indian population: A meta-analysis and meta-regression study

Rapid Relief of Gastroesophageal Reflux Disease (GERD) Symptoms With Sodium Alginate Antacid Suspension: An Indian Real-World Evidence Study

Background and objectives Gastroesophageal reflux disease (GERD) is a common gastrointestinal disorder characterized by troublesome symptoms affecting the quality of life. Sodium alginate antacid suspension provides quick and prolonged relief of symptoms due to its unique mechanism of action. The primary objective of this study was to evaluate improvement in GERD symptoms by assessing changes in symptom scores at the end of one week and to evaluate the responder rate. The secondary objective was to evaluate patient tolerability using the frequency and severity of adverse events and physician-reported outcomes. Methods This was a retrospective, observational data collection study that reviewed medical records of GERD patients who received sodium alginate antacid suspension (10-20 ml, 3-4 times daily) for one week. Data were retrieved, analyzed, translated into symptom scores (GERD Health-Related Quality of Life score), and classified based on disease severity. Primary outcomes were improvement in symptom scores (heartburn, regurgitation, swallowing difficulties, and bloating) and total scores at the end of treatment. The responder rates, physician-reported outcomes, and tolerability were also analyzed. Results Medical records for 10,000 patients treated with sodium alginate antacid suspension were reviewed. Out of these, data for 6,246 patients was further analyzed. Treatment with sodium alginate antacid suspension resulted in significant reductions in heartburn, regurgitation, swallowing difficulties, and bloating scores (p<0.001) in patients with moderate to severe GERD. The mean total GERD symptom score also decreased significantly from baseline (p<0.001). The responder rate, i.e., a reduction of ≥50% in the total symptom score from baseline to the end of one week, was 74%. Almost 90% of patients reported symptom improvement, but 2.22% of patients experienced adverse events. As per physicians, this suspension was effective in 96.64% of patients. Conclusion This real-world evidence study highlights rapid symptomatic relief in GERD patients with sodium alginate antacid suspension.

Association of Physicians of India Consensus Recommendations for Vonoprazan in Management of Acid Peptic Disorders

The suppression of gastric acid secretion has long been the cornerstone of treatment for acid peptic disorders (APDs). Proton pump inhibitors (PPIs) have played a central role in managing these conditions, but their effectiveness can be hindered by notable limitations such as refractoriness or treatment failure due to inadequate acid suppression in some gastroesophageal reflux disease (GERD) patients, nonadherence to prescribed regimens due to the complexity of dosing, variability of response, and nocturnal acid breakthrough, etc. Vonoprazan is a first-in-class potassium-competitive acid blocker (P-CAB), recently introduced in India and also approved in several countries such as Japan, South Korea, and the USA. Extensive clinical evidence suggests that vonoprazan offers more potent acid suppression than PPIs. This consensus from the Association of Physicians of India (API) has been developed with the objective of providing key recommendations for the appropriate clinical usage of vonoprazan across various subsets of APDs, thereby optimizing the existing therapeutic options and improving the care and management of APD patients.

Gastroesophageal Reflux Disease Among Undergraduate Medical Students in Egypt: Prevalence and Risk Factors

Background

Gastroesophageal reflux disease (GERD) is a prevalent gastrointestinal condition that has a detrimental impact on one's quality of life because of acid reflux causing damage to the esophagus. Primary symptoms consist of heartburn and regurgitation, although patients may also encounter chest pain, nausea, and dysphagia. Medical students may be particularly susceptible due to stressful lifestyles and unhealthy habits. This study investigates the prevalence of GERD among medical students in Egypt and explores associated risk factors.

Subjects and Methods

This is a cross-sectional observational study that was conducted among undergraduate medical students at 21 medical schools across Egypt. The study included 602 participants from medical schools. The study utilized a pre-designed, self-administered questionnaire that includes questions about sociodemographic and lifestyle attributes, accompanied by the GERDQ questionnaire used to diagnose gastroesophageal reflux disease.

Results

A total of 602 undergraduate medical students completed the questionnaire. The prevalence of GERD was found to be 28.4%, with heartburn and regurgitation being the most prevalent symptoms among participants. Univariate and multivariate logistic regression revealed family history of GERD and stress after medical school enrollment as significant predictors of GERD symptoms (p=0.043 and p=0.044, respectively).

Conclusion

GERD has become increasingly common among medical students in Egypt. Contributing factors include medical students' stressful lifestyles and familial predispositions. To address this, it is essential to implement counseling programs and raise awareness as initial steps toward reducing GERD prevalence.

Vegetarian Diet Reduced Gastroesophageal Reflux Disease in a Nationwide Longitudinal Survey in Taiwan

BACKGROUND/OBJECTIVES

This large, longitudinal follow-up cohort study aimed to explore how being a vegetarian and related factors impacted the incident gastroesophageal reflux disease (GERD) in a comprehensive Taiwanese cohort.

METHODS

The study cohort was enrolled from the Taiwan Biobank. Vegetarian status, duration of being a vegetarian, type of vegetarian diet, and whether or not the participants had GERD were recorded from self-reported surveys. Associations between vegetarian status, duration, and type of diet with incident GERD were analyzed with multivariate logistic regression with adjustments for confounding variables.

RESULTS

After excluding participants with pre-existing GERD, we included 23,714 participants into the study. Multivariable analysis showed that vegetarian status (current vs. never; hazard ratio [HR], 0.697; 95% confidence interval [CI], 0.546 to 0.889; p = 0.004) was significantly inversely associated with incident GERD; conversely, ever being a vegetarian was not associated (p = 0.489). In addition, those who had been a vegetarian for 6 years or more had 0.72 times lower risk of GERD compared to those who had never been a vegetarian (HR, 0.717; 95% CI 0.558 to 0.922, p = 0.009). No significant differences were observed regarding the type of vegetarian diet with incident GERD.

CONCLUSIONS

The results showed that following a vegetarian diet was an independent protective factor for incident GERD, with a significant protective effect observed in those who adhered to a vegetarian diet for at least 6 years. Future research is warranted to explore the underlying mechanisms and whether adopting a vegetarian diet can decrease the incidence of GERD.

No Association between Helicobacter pylori and Gastroesophageal Reflux Disease: A Comprehensive Risk Factor Analysis in North Indian Patients

Background:

The relationship between gastroesophageal reflux disease (GERD) and Helicobacter pylori infection is a complicated topic. This study aimed to evaluate the association between H. pylori infection and GERD and identify the associated risk factors in North India.

Methods:

All individuals who were referred for an endoscopy because they had dyspepsia were included in a cross-sectional study. Using endoscopic assessment, GERD was diagnosed. As a comparison group, patients with normal esophageal function were chosen. H. pylori was cultured and genotyped to assess the virulent genes such as cagA, vacA, and iceA. The relationship of H. pylori infection with GERD and its associated risk factors were estimated with Chi-square analysis, odds ratios, and 95% confidence intervals using multiple logistic regression analysis.

Results:

In total, 420 patients were included in this study, of whom 335 (79.8%) had GERD. The mean age was 44.01 ± 16.52 years. Overall, 143 (34%) patients were positive for H. pylori infection. cagA-negative H. pylori isolates were significantly associated with the GERD group. Variables such as gender, age, alcohol, smoking, body mass index (BMI), smoking, and hiatus hernia in patients had no significant association with H. pylori infection. However, increased age, gender, Frequency Scale for the Symptoms of GERD (FSSG) score, BMI, and presence of hiatus hernia were significantly associated with the GERD group.

Conclusion:

In our results, there was no association between H. pylori infection and GERD. The risk factors for GERD were age, gender, FSSG score, BMI, and hiatus hernia. Further studies are recommended.

High Dose Pantoprazole for Gastroesophageal Reflux Disease: Need, Evidence, Guidelines and Our Experience

Gastroesophageal reflux disease (GERD) has a pooled prevalence of 15.2% in India with varying presentation in different subset of patients. The approach towards the management of GERD includes use of monotherapy or a combination of OTCs like antacids and/or prescription drugs like H2 receptor antagonists and proton pump inhibitors (PPI). Better efficacy and safety profile of PPIs have contributed to its wide spread use as compared with other drugs for the same indication. Among PPIs, most of the healthcare professionals prefer to prescribe pantoprazole in India. Standard dose of Pantoprazole (40 mg) is unable to meet the needs in case of extraesophageal symptoms, partial responders, patients with concomitant use of non-steroidal anti-inflammatory drugs (NSAIDs), or severe presentation in cases of overweight/obese patients. Multiple guidelines recommend doubling the dose of PPI in such cases. Twice daily dosing of PPI may reduce compliance. Thus, there is a need for a higher dose of Pantoprazole (80 mg) to be prescribed once daily in these cases so that improved compliance leads to better outcomes. The use of dual release Pantoprazole 80 mg may help to improve compliance and also enhance the time for which acid suppression takes place. In this review, we discuss the use of higher dose PPI based on scientific evidence and experience of clinicians for the same.

How to cite this article

Upadhyay R, Soni NK, Kotamkar AA, et al. High Dose Pantoprazole for Gastroesophageal Reflux Disease: Need, Evidence, Guidelines and Our Experience. Euroasian J Hepato-Gastroenterol 2024;14(1):86-91.

Guidelines on optimizing the use of proton pump inhibitors: PPI stewardship

Proton pump inhibitors (PPIs) have been available for over three decades and are among the most commonly prescribed medications. They are effective in treating a variety of gastric acid-related disorders. They are freely available and based on current evidence, use of PPIs for inappropriate indications and duration appears to be common. Over the years, concerns have been raised on the safety of PPIs as they have been associated with several adverse effects. Hence, there is a need for PPI stewardship to promote the use of PPIs for appropriate indication and duration. With this objective, the Indian Society of Gastroenterology has formulated guidelines on the rational use of PPIs. The guidelines were developed using a modified Delphi process. This paper presents these guidelines in detail, including the statements, review of literature, level of evidence and recommendations. This would help the clinicians in optimizing the use of PPIs in their practice and promote PPI stewardship.

Patterns of multimorbidity among a community-based cohort in rural India

Background

Multimorbidity estimates are expected to increase in India primarily due to the population aging. However, there is a lack of research estimating the burden of multimorbidity in the Indian context using a validated tool. We estimated the prevalence and determinants of multimorbidity amongst the adult population of the rural Uddanam region, Andhra Pradesh.

Methods

This community-based cross-sectional study was conducted as a part of an ongoing research program. Multistage cluster sampling technique was used to select 2419 adult participants from 40 clusters. Multimorbidity was assessed using Multimorbidity Assessment Questionnaire for Primary Care (MAQ-PC) tool, collecting information on 13 chronic diseases. Patient Health Questionnaire (PHQ-12) was used to screen for depression. Multiple logistic regression was conducted to identify the strongest determinants of multimorbidity.

Results

Of the 2419 participants, 2289 completed the MAQ-PC tool. Mean age (standard deviation) of participants was 48.1 (13.1) years. The overall prevalence of multimorbidity was 58.5% (95% CI 56.5-60.6); with 30.7%, 15.6%, and 12.2% reporting two, three, and four chronic conditions, respectively. Acid peptic disease-musculoskeletal disease (44%) and acid peptic disease-musculoskeletal disease-hypertension (14.9%) were the most common dyad and triad. Among metabolic diseases, diabetes-hypertension (28.3%) and diabetes-hypertension-chronic kidney disease (7.6%) were the most common dyad and triad, respectively. Advancing age, female gender, and being obese were the strongest determinates of the presence of multimorbidity. Depression was highly prevalent among the study population, and participants with higher PHQ-12 score had 3.7 (2.5-5.4) greater odds of having multimorbidity.

Conclusions

Our findings suggest that six of 10 adults in rural India are affected with multimorbidity. We report a higher prevalence of multimorbidity as compared with other studies conducted in India. We also identified vulnerable groups which would guide policy makers in developing holistic care packages for individuals with multimorbidity.

Nocturnal acid breakthrough and esophageal acidification during treatment with dexlansoprazole as compared to omeprazole in patients with gastroesophageal reflux disease

BACKGROUND

Nocturnal acid breakthrough (NAB) may differ based on duration of proton pump inhibitor (PPI) action and Helicobacter pylori (H. pylori) infection; NAB may influence esophageal acidification (EA) and mucosal damage. Dexlansoprazole, a long-acting PPI, was not compared with omeprazole for NAB, gastric acid suppression, and EA in relation to H. pylori infection.

METHODS

In this prospective open-label comparative observational study, gastroesophageal reflux disease (GERD) patients were evaluated using 24-h dual-channel pH-impedance monitoring while on dexlansoprazole (60 mg, n = 39) and omeprazole (20 mg, n = 41) to study the degree of gastric acid suppression, esophageal acid exposure, and NAB (primary outcome measures). H. pylori was detected by rapid urease test and histology.

RESULTS

NAB tended to be frequent with omeprazole than dexlansoprazole (33/41 [80.5%] vs. 23/39 [59%]; p = 0.06). Though nocturnal mean esophageal pH was comparable between the dexlansoprazole and omeprazole groups, its duration was less with the former (181.5 [15.2-334.2] vs. 283 [158-366] min, p = 0.03). NAB was as frequent in the H. pylori-infected than the non-infected group (11/19 [57.9%] vs. 45/61 [73.8%]; p = 0.1). The nocturnal gastric and esophageal pH in the H. pylori-infected group was higher than in the non-infected group (4.6 ± 1.7 vs. 4 ± 1.6, p = 0.157; 6.1 ± 0.6 vs. 5.8 ± 0.6, p = 0.128). Dexlansoprazole tended to increase 24-h and nocturnal mean gastric pH among H. pylori-infected more than omeprazole (5.9 ± 1.1 vs. 4.2 ± 1.7, p = 0.023; 5.7 ± 1.2 vs. 3.8 ± 1.5, p = 0.006).

CONCLUSION

Dexlansoprazole is more effective than omeprazole in suppressing gastric acid secretion, resulting in lesser EA and NAB, particularly in the presence of H. pylori.

Are we Missing Barrett's Esophagus in Our Busy Endoscopy Practice? Improving Detection

Barrett's esophagus (BE) denotes the replacement of stratified squamous epithelium of esophagus by columnar epithelium. It is associated with a significantly increased risk of esophageal adenocarcinoma and hence patients with BE are advised endoscopic surveillance for early detection of dysplastic and neoplastic lesions. Esophageal cancer is the sixth most common cancer in terms of incidence and mortality in India. Around 15 to 25% of esophageal cancers are adenocarcinoma. BE is likely to be an important precursor of esophageal adenocarcinoma and we may be missing patients with BE in our busy endoscopy practice. The detection of BE may be improved by identifying high-risk groups, performing thorough endoscopic examination, and applying newer imaging techniques. The high-risk group includes patients with chronic gastroesophageal reflux disease, obesity, smoking, etc. During endoscopic examination, a careful assessment of the gastroesophageal junction and identification of important landmarks such as gastroesophageal junction and Z line are essential to detect BE. Management of BE depends on the detection of dysplasia and for this four quadrant mucosal biopsy is recommended every 1 to 2 cm. However, random biopsy samples only a small area of mucosa and advanced technologies for real-time detection of dysplasia and neoplasia may overcome this limitation. In this review, we discuss the current scenario of BE in India and ways to improve the detection of BE including dysplastic lesions.