Melatonin for the treatment of gastroesophageal reflux disease; protocol for a systematic review and meta-analysis

Integrative Approaches to Managing Gut Health

PURPOSE OF REVIEW

To summarize key integrative approaches to managing common gastrointestinal conditions.

RECENT FINDINGS

Lifestyle interventions like diet, exercise, and stress reduction impact the gut microbiome and gastrointestinal symptoms. Evidence supports mind-body therapies, herbs, certain supplements, and other modalities as complimentary approaches, when appropriate, for common conditions like irritable bowel syndrome or gastroesophageal reflux disease. An integrative approach optimizes both conventional treatments and incorporates lifestyle modifications, complimentary modalities, and the doctor-patient relationship.

Is the Addition of Sublingual Melatonin to Omeprazole Superior to Omeprazole Alone in the Management of Gastroesophageal Reflux Disease Symptoms: A Clinical Trial

BACKGROUND/AIMS

Proton pump inhibitors are frequently used to treat gastroesophageal reflux disease, but their effect is restricted. The present study aimed to investigate whether the addition of sublingual melatonin to omeprazole was effective in the treatment of gastro gastroesophageal reflux disease symptoms.

MATERIALS AND METHODS

This was a randomized double-blind clinical trial. A total of 78 patients with gastro gastroesophageal reflux disease were randomly allocated to either omeprazole 20 mg/d plus sublingual melatonin (3 mg/d) or omeprazole 20 mg/d plus placebo for 4 weeks. The selected patients had histories of heartburn and regurgitation and a score ≤32 on the Frequency Scale for the Symptoms of gastroesophageal reflux disease (FSSG). The outcome measures for the assessment of treatment efficacy were heartburn, epigastric pain and the Frequency Scale for the Symptoms of gastroesophageal reflux disease score. Safety and quality of life were evaluated in the patients as the secondary outcomes too.

RESULTS

Seventy-two out of 78 eligible patients completed this trial (35 in the melatonin group and 37 in the placebo group). Heartburn, epigastric pain, and Frequency Scale for the Symptoms of gastroesophageal reflux disease score declined significantly in the melatonin group compared to the placebo group (P = .04, P = .03, and P = .0001, respectively). Moreover, the quality of life score was significantly higher in the melatonin group compared with the placebo group (P = .0001). Adverse events were similarly observed in the 2 groups (P = .55), and there were no serious adverse events.

CONCLUSION

The combination of sublingual melatonin (3 mg/day) with omeprazole (20 mg/day) may be more effective than omeprazole (20 mg/day) alone in the treatment of gastroesophageal reflux disease.

Serotonin and Melatonin in Human Lower Gastrointestinal Tract

BACKGROUND AND AIMS

Melatonin is a ubiquitous hormone produced not only by the pineal gland but also by other organs and tissues. It is involved in the regulation of several gastrointestinal functions. The main cells responsible for the production and release of extrapineal melatonin are the enterochromaffin (EC) cells that produce serotonin. They are involved in the pathogenesis of neuromotor disorders that characterize functional gastrointestinal disorders and in the pathophysiology of inflammatory intestinal diseases. Our aim was the immunohistochemical highlighting on biopsy samples of normal gastrointestinal mucosa and in ulcerative colitis (UC) of immunoreactive cells for melatonin and serotonin in order to identify any differences in their distribution.

MATERIALS AND METHODS

Our prospective case-control study involves the highlighting on human mucosal biopsies of immunoreactive cells for melatonin and serotonin. All patients undergoing colonoscopy + ileoscopy were considered eligible for the study, divided into two groups: 1. patients with active ulcerative colitis (UC); 2. control group consisting of patients undergoing endoscopic examination for colorectal cancer screening.

RESULTS

Twenty-one patients were enrolled. The controls had a higher concentration of EC cells containing 5HT particularly in the rectum (p value ≤ 0.05). In patients with active colitis the expression of 5-HT-iR was greater in all tracts of the colon. The correlation analysis in UC patients shows that a higher expression of 5-HT-iR+ cells corresponds to a lower extension of the disease and a greater severity of the same.

CONCLUSIONS

5HT+ cells decreased in the case of UC compared to healthy controls. In the severe disease, there was an increase in the expression of melatonin-secreting cells, probably as a compensatory response to the inflammation and oxidative stress. This increase is negatively correlated with the extent of the disease and positively with the severity of the same.

WAO-ARIA consensus on chronic cough - Part III: Management strategies in primary and cough-specialty care. Updates in COVID-19

Background

Chronic cough management necessitates a clear integrated care pathway approach. Primary care physicians initially encounter the majority of chronic cough patients, yet their role in proper management can prove challenging due to limited access to advanced diagnostic testing. A multidisciplinary approach involving otolaryngologists and chest physicians, allergists, and gastroenterologists, among others, is central to the optimal diagnosis and treatment of conditions which underly or worsen cough. These include infectious and inflammatory, upper and lower airway pathologies, or gastro-esophageal reflux. Despite the wide armamentarium of ancillary testing conducted in cough multidisciplinary care, such management can improve cough but seldom resolves it completely. This can be due partly to the limited data on the role of tests (eg, spirometry, exhaled nitric oxide), as well as classical pharmacotherapy conducted in multidisciplinary specialties for chronic cough. Other important factors include presence of multiple concomitant cough trigger mechanisms and the central neuronal complexity of chronic cough. Subsequent management conducted by cough specialists aims at control of cough refractory to prior interventions and includes cough-specific behavioral counseling and pharmacotherapy with neuromodulators, among others. Preliminary data on the role of neuromodulators in a proof-of-concept manner are encouraging but lack strong evidence on efficacy and safety.

Objectives

The World Allergy Organization (WAO)/Allergic Rhinitis and its Impact on Asthma (ARIA) Joint Committee on Chronic Cough reviewed the recent literature on management of chronic cough in primary, multidisciplinary, and cough-specialty care. Knowledge gaps in diagnostic testing, classical and neuromodulator pharmacotherapy, in addition to behavioral therapy of chronic cough were also analyzed.

Outcomes

This third part of the WAO/ARIA consensus on chronic cough suggests a management algorithm of chronic cough in an integrated care pathway approach. Insights into the inherent limitations of multidisciplinary cough diagnostic testing, efficacy and safety of currently available antitussive pharmacotherapy, or the recently recognized behavioral therapy, can significantly improve the standards of care in patients with chronic cough.

Effectiveness of Nutritional Ingredients on Upper Gastrointestinal Conditions and Symptoms: A Narrative Review

Nutritional ingredients, including various fibers, herbs, and botanicals, have been historically used for various ailments. Their enduring appeal is predicated on the desire both for more natural approaches to health and to mitigate potential side effects of more mainstream treatments. Their use in individuals experiencing upper gastrointestinal (GI) complaints is of particular interest in the scientific space as well as the consumer market but requires review to better understand their potential effectiveness. The aim of this paper is to review the published scientific literature on nutritional ingredients for the management of upper GI complaints. We selected nutritional ingredients on the basis of mentions within the published literature and familiarity with recurrent components of consumer products currently marketed. A predefined literature search was conducted in Embase, Medline, Derwent drug file, ToXfile, and PubMed databases with specific nutritional ingredients and search terms related to upper GI health along with a manual search for each ingredient. Of our literature search, 16 human clinical studies including nine ingredients met our inclusion criteria and were assessed in this review. Products of interest within these studies subsumed the categories of botanicals, including fiber and combinations, and non-botanical extracts. Although there are a few ingredients with robust scientific evidence, such as ginger and a combination of peppermint and caraway oil, there are others, such as melatonin and marine alginate, with moderate evidence, and still others with limited scientific substantiation, such as galactomannan, fenugreek, and zinc-l-carnosine. Importantly, the paucity of high-quality data for the majority of the ingredients analyzed herein suggests ample opportunity for further study. In particular, trials with appropriate controls examining dose-response using standardized extracts and testing for specific benefits would yield precise and effective data to aid those with upper GI symptoms and conditions.

Association between Shift Work and Reflux Esophagitis: The Kangbuk Samsung Health Study

This cross-sectional study investigated the relationship between shift work and reflux esophagitis verified by endoscopic findings. Participants underwent a comprehensive health examination and esophagogastroduodenoscopy between January 2011 and December 2018. We examined endoscopic findings and performed multivariate-adjusted regression analysis of the association between shift work and reflux esophagitis using multiple demographic and clinical factors. Among the 247,450 participants, 49,767 (20.1%) had reflux esophagitis; Los Angeles (LA)-M (31,132, 12.6%) was most common, followed by LA-A (16,213, 6.6%), LA-B (2333, 0.9%), and ≥LA-C (89, 0.04%). The multivariate-fully adjusted odds ratio (OR) of overall reflux esophagitis for shift work compared to fixed day work was 1.15 (95% confidence interval [CI]: 1.11–1.19). When classified according to shift work type and severity of reflux esophagitis, the ORs of LA-A for regular day and night, and irregular shifts compared to fixed day works were 1.14 (95% CI: 1.03–1.26) and 1.26 (95% CI: 1.11–1.44), respectively. However, there was no significant association between any shift work schedule and ≥LA-B. Overall, we demonstrated the cross-sectional association between shift work (especially rotating and irregular shifts) and mild reflux esophagitis (≤LA-A) compared with daily fixed time shifts.

Rotating night shift work is associated with an increased risk of gastroesophageal reflux disease (GERD) symptoms among workers in China: A cross-sectional study

AIMS OF THE STUDY

Increasing studies suggest a significant association between night shift work and an increased risk of type 2 diabetes, obesity and other metabolic disorders. However, the available evidence of the association of rotating night shift work with gastroesophageal reflux disease (GERD) is limited. Herein, we hypothesised a link between the GERD risk and rotating night shift work among workers in China.

METHODS USED TO CONDUCT THE STUDY

A total of 2027 workers who completed a comprehensive health checkup were included. Logistic regression was used to investigate the link between rotating night shift work and the risk of GERD symptoms. Receiver operating characteristic (ROC) curve analysis was used to assess the multivariable model's diagnostic value for identifying GERD symptoms among workers.

RESULTS OF THE STUDY

In total, 556 (27.4%) individuals had GERD symptoms among 2027 workers. Multivariate analysis showed five independent factors for GERD: rotating night shift work (OR = 3.66, 95% CI: 2.52-5.40), age (OR = 2.53, 95% CI: 1.67-3.78), smoking (OR = 3.70, 95% CI: 2.63-5.21), Helicobacter pylori (H. pylori) infection (OR = 0.68, 95% CI: 0.48-0.96) and obesity (OR = 3.04, 95% CI: 2.43-3.83). A five-variable model based on five independent factors provided an area under a ROC curve (AUROC) of 0.80 (95% CI: 0.78-0.81) for identifying GERD symptoms among workers.

CONCLUSIONS DRAWN FROM THE STUDY AND CLINICAL IMPLICATIONS

Rotating night shift work is independently associated with an increased risk of GERD symptoms. Moreover a five-variable model (rotating night shift work, age, smoking, H pyori infection and obesity) can help identify individuals at high risk for GERD symptoms among workers in China.

Focus on gastroesophageal reflux disease in patients with cystic fibrosis

Gastroesophageal reflux disease (GERD) is a common gastrointestinal disorder in cystic fibrosis (CF), and based on various studies, its prevalence is elevated since childhood. There are several pathogenetic mechanisms on the basis of association between CF and GERD. However, there are no specific guidelines for GERD in CF patients, so diagnosis is based on guidelines performed on patients not affected by CF. The aim of this review is to provide the pathophysiology, diagnostic and therapeutic options, complications, and future directions in the management of GERD patients with CF.

Ex Vivo Electrochemical pH Mapping of the Gastrointestinal Tract in the Absence and Presence of Pharmacological Agents

Ex vivo pH profiling of the upper gastrointestinal (GI) tract (of a mouse), using an electrochemical pH probe, in both the absence and presence of pharmacological agents aimed at altering acid/bicarbonate production, is reported. Three pH electrodes were first assessed for suitability using a GI tract biological mimic buffer solution containing 0.5% mucin. These include a traditional glass pH probe, an iridium oxide (IrOx)-coated electrode (both operated potentiometrically), and a quinone (Q) surface-integrated boron-doped diamond (BDD-Q) electrode (voltammetric). In mucin, the time scale for both IrOx and glass to provide a representative pH reading was in the ∼100's of s, most likely due to mucin adsorption, in contrast to 6 s with the BDD-Q electrode. Both the glass and IrOx pH electrodes were also compromised on robustness due to fragility and delamination (IrOx) issues; contact with the GI tissue was an experimental requirement. BDD-Q was deemed the most appropriate. Ten measurements were made along the GI tract, esophagus (1), stomach (5), and duodenum (4). Under buffer only conditions, the BDD-Q probe tracked the pH from neutral in the esophagus to acidic in the stomach and rising to more alkaline in the duodenum. In the presence of omeprazole, a proton pump inhibitor, the body regions of the stomach exhibited elevated pH levels. Under melatonin treatment (a bicarbonate agonist and acid inhibitor), both the body of the stomach and the duodenum showed elevated pH levels. This study demonstrates the versatility of the BDD-Q pH electrode for real-time ex vivo biological tissue measurements.