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Tack J, Vladimirov B, Horny I, Chong CF, Eisner J, Czerniak R, Takanami Y. Randomized clinical trial: A double-blind, proof-of-concept, phase 2 study evaluating the efficacy and safety of vonoprazan 20 or 40 mg versus esomeprazole 40 mg in patients with symptomatic gastro-esophageal reflux disease and partial response to a healing dose of a proton-pump inhibitor. Neurogastroenterol Motil 2023; 35:e14468. [PMID: 36178335 DOI: 10.1111/nmo.14468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 08/25/2022] [Accepted: 09/12/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Proton-pump inhibitors (PPIs) are cornerstone treatments for gastro-esophageal reflux disease (GERD); however, evidence suggests that most patients exhibit partial response to PPIs, suggesting the need for novel therapies that can provide an improved and sustained increase in gastric pH. AIMS This study aimed to determine the effect of vonoprazan, a novel, orally active small-molecule potassium-competitive acid blocker, versus esomeprazole, a PPI, in preventing heartburn symptoms over a 4-week treatment period in patients with GERD and a partial response to esomeprazole treatment. METHODS This randomized, double-blind, proof-of-concept, phase 2 clinical trial was conducted between 2016 and 2018 at 39 sites across Europe and designed to evaluate the efficacy and safety of vonoprazan 20 mg once daily (q.d.) and 40 mg q.d. versus esomeprazole 40 mg q.d. after 1:1:1 randomization of symptomatic patients with GERD and a partial response to a healing dose of esomeprazole. RESULTS Overall, 256 eligible patients (female, 59.4%; mean age, 52.6 years) received vonoprazan 20 mg (n = 85), vonoprazan 40 mg (n = 85), or esomeprazole 40 mg (n = 86); mean (SD) percentages of heartburn-free 24-h periods during double-blind treatment were 36.7% (33.4%), 36.5% (35.6%), and 38.4% (34.8%), respectively, with no intergroup statistical significance. Vonoprazan exposure increased proportionally from the 20-mg to 40-mg dose (mean Cmax : 23.3 ng/ml to 47.1 ng/ml, respectively). Most treatment-emergent adverse events were mild, with no deaths reported. CONCLUSIONS No statistically significant difference in efficacy and safety was observed among treatment groups, and vonoprazan was well tolerated. The trial is registered with the National Board of Health (EudraCT: 2015-001154-14) database.
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Affiliation(s)
- Jan Tack
- Department of Gastroenterology, University Hospitals Leuven, Leuven, Belgium
| | - Borislav Vladimirov
- Department of Gastroenterology, University Hospital "Queen Giovanna- ISUL", Medical University of Sofia, Sofia, Bulgaria
| | - Ivo Horny
- Department of Gastroenterology and Internal medicine, Strakonice Hospital, Czech Republic
| | - Chui Fung Chong
- Currently Hoffmann-La Roche, Formerly Takeda Development Center Asia, Basel, Switzerland
| | - Jessica Eisner
- Formerly Takeda Pharmaceuticals International Co., Takeda Pharmaceuticals International Co., Cambridge, USA
| | - Richard Czerniak
- Takeda Pharmaceuticals International Co., Cambridge, Massachusetts, USA
| | - Yohei Takanami
- Takeda Pharmaceuticals International Co., Cambridge, Massachusetts, USA
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Armstrong D, Hungin AP, Kahrilas PJ, Sifrim D, Sinclair P, Vaezi MF, Sharma P. Knowledge gaps in the management of refractory reflux-like symptoms: Healthcare provider survey. Neurogastroenterol Motil 2022; 34:e14387. [PMID: 35502888 PMCID: PMC9787909 DOI: 10.1111/nmo.14387] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 03/28/2022] [Accepted: 04/11/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Refractory reflux-like symptoms have a substantial impact on patients and healthcare providers. The aim of the survey was to qualitatively assess the needs and attitudes of practicing clinicians around the management of refractory reflux symptoms and refractory gastroesophageal reflux disease (rGERD). METHODS An International Working Group for the Classification of Oesophagitis (IWGCO) steering committee invited clinicians to complete an online survey including 17 questions. KEY RESULTS Of the 113 clinicians who completed the survey, 70% were GIs, 20% were primary care physicians, and 10% were other specialties. Functional heartburn was considered the most common reason for an incomplete response to proton pump inhibitor (PPI) therapy (82%), followed by stress/anxiety (69%). More GIs identified esophageal hypersensitivity as a cause, while more non-GIs identified esophageal dysmotility and non-reflux-related esophageal conditions. As the first step, most clinicians would order investigations (70-88%). Overall, 72% would add supplemental therapy for patients with partial response, but only 58% for those with non-response. Antacid/alginate was the most common choice overall, while non-GIs were more likely to add a prokinetic than were GIs (47.8 vs. 24.1%). Approximately 40% of clinicians would switch PPIs in patients with partial response, but only 29% would do so in non-responders. Preferences for long-term therapy were highly variable. The most common initial investigation was upper endoscopy. Choice of esophageal manometry and pH monitoring was more variable, with no clear preference for whether pH monitoring should be conducted on, or off, PPI therapy. CONCLUSIONS AND INFERENCES The survey identified a number of challenges for clinicians, especially non-GI physicians, treating patients with refractory reflux-like symptoms or rGERD on a daily basis.
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Affiliation(s)
- David Armstrong
- Division of Gastroenterology & Farncombe Family Digestive Health Research InstituteMcMaster UniversityHamiltonOntarioCanada
| | - Amrit Pali Hungin
- Faculty of Medical SciencesNewcastle UniversityNewcastle upon TyneUK
| | - Peter J. Kahrilas
- Division of GastroenterologyNorthwestern UniversityChicagoIllinoisUSA
| | - Daniel Sifrim
- Barts and The London School of Medicine and DentistryQueen Mary, University of LondonLondonUK
| | | | - Michael F. Vaezi
- Division of GastroenterologyVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Prateek Sharma
- Division of Gastroenterology and HepatologyVeterans Affairs Medical CenterUniversity of Kansas School of MedicineKansas CityMissouriUSA
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Anderson R, Streck S, Hughes G, Suterfield B, Kee M, Wise A, Hillman C, Ottwell R, Hartwell M, Vassar M. Evaluating reporting of patient-reported outcomes in peptic ulcer disease: a meta-epidemiological study of randomized controlled trials. Expert Rev Pharmacoecon Outcomes Res 2022; 22:1253-1260. [PMID: 36073013 DOI: 10.1080/14737167.2022.2122955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Peptic ulcer disease (PUD) can significantly affect quality of life (QoL). These QoL outcomes are often patient-reported, and their inclusion in clinical trials supplements efficacy outcomes to provide the patients' perspective. This study aimed to assess existing literature for completeness of PRO reporting across randomized controlled trials (RCTs) evaluating PUD. METHODS This was a meta-epidemiological, cross-sectional study which assessed completeness of reporting among RCTs addressing management of PUD. We conducted a comprehensive literature search using MEDLINE, Embase, and the Cochrane Register of Controlled Trials to identify RCTs with a PRO as a primary or secondary outcome. These RCTs were assessed for completion of reporting according to the PRO adaptation of Consolidated Standards of Reporting Trials checklist. RCTs were also assessed for Risk of Bias (RoB) using the Cochrane RoB 2.0 tool. RESULTS Masked, duplicate screening of 829 results from our search yielded a final sample of 35 RCTs. The average completeness of reporting was 32.9% according to the CONSORT-PRO adaptation. Twenty-one (of 35; 60%) of the RCTs were assessed as having 'high' risk of bias and nine (of 35; 25.71%) were assessed as having 'some concerns' for risk of bias. Bivariate regression found completeness of reporting to be positively associated with increased PRO follow-up duration, larger sample size, and studies which report conflicts of interest. CONCLUSION RCTs examining the treatment and prevention of PUD with PROs as an outcome measure have deficient reporting and 'high' risk of bias according to the CONSORT-PRO and Cochrane RoB guidelines.
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Affiliation(s)
- Reece Anderson
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, Oklahoma, USA
| | - Sam Streck
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, Oklahoma, USA
| | - Griffin Hughes
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, Oklahoma, USA
| | - Bethany Suterfield
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, Oklahoma, USA
| | - Micah Kee
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, Oklahoma, USA
| | - Audrey Wise
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, Oklahoma, USA
| | - Cody Hillman
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, Oklahoma, USA
| | - Ryan Ottwell
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, Oklahoma, USA.,Department of Internal Medicine, University of Oklahoma, School of Community Medicine, Tulsa, OK, United States
| | - Micah Hartwell
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, Oklahoma, USA.,Department of Psychiatry and Behavioral Sciences, Oklahoma State University Center for Health Sciences, Tulsa, Oklahoma, USA
| | - Matt Vassar
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, Oklahoma, USA.,Department of Psychiatry and Behavioral Sciences, Oklahoma State University Center for Health Sciences, Tulsa, Oklahoma, USA
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Boarino V, Raguzzi I, Marocchi M, Merighi A. Symptomatic response to GERDOFF® in patients with gastro-esophageal reflux disease and poor response to alginates: an exploratory, post-market, open-label study. TURKISH JOURNAL OF GASTROENTEROLOGY 2020; 31:466-473. [PMID: 32721918 DOI: 10.5152/tjg.2020.19327] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND/AIMS A novel medical device based on hyaluronic acid, chondroitin sulphate plus aluminum hydroxide (GERDOFF®, melt-in-mouth tablets) showed efficacy in reducing GER-related symptoms. This exploratory, open-label study evaluated symptomatic effects of a 14-day treatment with GERDOFF® in GERD patients. MATERIALS AND METHODS GERD Impact Scale (GIS) questionnaire was filled at baseline visit, after 7 and 14 days of treatment; patients' Global Satisfaction was evaluated at the final visit. Primary endpoint was the reduction of heartburn episodes per week; secondary endpoints were GERD-related symptoms, patients' satisfaction, and safety. RESULTS Forty patients were included, 22 were on stable therapy with proton pump inhibitor (PPI). Compared to baseline, the days with heartburn episodes and the GIS score progressively decreased during the first (p<0.0001) and the second week of treatment (p<0.0001). Heartburn episodes per week (p<0.0001) and the GIS score (p<0.0001) decreased in the first and the last 7 days of 14-day treatment and did not differ between patients on and off PPI. The treatment was safe and well-tolerated, and it was rated as very good (46.2%) or good (43.6%) on the satisfaction questionnaire. CONCLUSION GERDOFF® could effectively treat GER symptoms in patients not responding to PPI or alginate-based formulation. ISRCTN_15143752.
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Affiliation(s)
- Valentina Boarino
- Department of Gastroenterology and Digestive Endoscopy, University of Modena, Modena, Italy
| | - Ivana Raguzzi
- Department of Gastroenterology and Digestive Endoscopy, Hospital of Cernusco sul Naviglio, Milan, Italy
| | - Margherita Marocchi
- Department of Gastroenterology and Digestive Endoscopy, University of Modena, Modena, Italy
| | - Alberto Merighi
- Department of Gastroenterology and Digestive Endoscopy, University of Modena, Modena, Italy
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Lai K, Shen H, Zhou X, Qiu Z, Cai S, Huang K, Wang Q, Wang C, Lin J, Hao C, Kong L, Zhang S, Chen Y, Luo W, Jiang M, Xie J, Zhong N. Clinical Practice Guidelines for Diagnosis and Management of Cough-Chinese Thoracic Society (CTS) Asthma Consortium. J Thorac Dis 2018; 10:6314-6351. [PMID: 30622806 PMCID: PMC6297434 DOI: 10.21037/jtd.2018.09.153] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 09/10/2018] [Indexed: 12/26/2022]
Affiliation(s)
- Kefang Lai
- State Key Laboratory of Respiratory Diseases, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou Institute of Respiratory Health, Guangzhou 510120, China
| | - Huahao Shen
- The Second Hospital Affiliated to Medical College of Zhejiang University, Hangzhou 310009, China
| | - Xin Zhou
- Shanghai Jiaotong University Affiliated Shanghai No. 1 People’s Hospital, Shanghai 200080, China
| | - Zhongmin Qiu
- Tongji Affiliated Tongji Hospital, Shanghai 200065, China
| | - Shaoxi Cai
- Southern Medical University Affiliated Nanfang Hospital, Guangzhou 510515, China
| | - Kewu Huang
- Capital Medical University Affiliated Beijing Chaoyang Hospital, Beijing 100020, China
| | | | - Changzheng Wang
- Xinqiao Hospital, Third Military Medical University, Chongqing 400037, China
| | - Jiangtao Lin
- China-Japan Friendship Hospital, Beijing 100029, China
| | - Chuangli Hao
- Children’s Hospital of Soochow University, Suzhou 215025, China
| | - Lingfei Kong
- The First Hospital of China Medical University, Shenyang 110001, China
| | - Shunan Zhang
- China-Japan Friendship Hospital, Beijing 100029, China
| | - Yaolong Chen
- Evidence-based Medical Center of Lanzhou University, Lanzhou 730000, China
| | - Wei Luo
- State Key Laboratory of Respiratory Diseases, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou Institute of Respiratory Health, Guangzhou 510120, China
| | - Mei Jiang
- State Key Laboratory of Respiratory Diseases, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou Institute of Respiratory Health, Guangzhou 510120, China
| | - Jiaxing Xie
- State Key Laboratory of Respiratory Diseases, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou Institute of Respiratory Health, Guangzhou 510120, China
| | - Nanshan Zhong
- State Key Laboratory of Respiratory Diseases, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou Institute of Respiratory Health, Guangzhou 510120, China
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Barmpalexis P, Grypioti A. Development of a new esomeprazole delayed release gastro-resistant pellet formulation with improved storage stability. Drug Dev Ind Pharm 2018; 44:942-952. [DOI: 10.1080/03639045.2017.1422513] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Panagiotis Barmpalexis
- Department of Pharmaceutical Technology, School of Pharmacy, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Pharmaceutical Research and Development Department, Rontis Hellas S.A., Maroussi, Greece
| | - Agni Grypioti
- Pharmaceutical Research and Development Department, Rontis Hellas S.A., Maroussi, Greece
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7
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Hillman L, Yadlapati R, Thuluvath AJ, Berendsen MA, Pandolfino JE. A review of medical therapy for proton pump inhibitor nonresponsive gastroesophageal reflux disease. Dis Esophagus 2017; 30:1-15. [PMID: 28859358 PMCID: PMC5788178 DOI: 10.1093/dote/dox055] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 04/20/2017] [Indexed: 12/11/2022]
Abstract
Up to 40% of patients report persistent gastroesophageal reflux disease (GERD) symptoms despite proton pump inhibitor (PPI) therapy. This review outlines the evidence for medical therapy for PPI nonresponsive GERD. A literature search for GERD therapies from 2005 to 2015 in PubMed, EMBASE, Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews identified 2928 unique citations. Of those, 40 unique articles specific to the impact of PPI metabolizer genotype on PPI response and the use adjunctive medical therapies were identified. Thirteen articles reported impacts on CYP genotypes on PPI metabolism demonstrating lower endoscopic healing rates in extensive metabolizers; however, outcomes across genotypes were more uniform with more CYP independent PPIs rabeprazole and esomeprazole. Twenty-seven publications on 11 adjunctive medications showed mixed results for adjunctive therapies including nocturnal histamine-2 receptor antagonists, promotility agents, transient lower esophageal sphincter relaxation inhibitors, and mucosal protective agents. Utilizing PPI metabolizer genotype or switching to a CYP2C19 independent PPI is a simple and conservative measure that may be useful in the setting of incomplete acid suppression. The use of adjunctive medications can be considered particularly when the physiologic mechanism for PPI nonresponse is suspected. Future studies using adjunctive medications with improved study design and patient enrollment are needed to better delineate medical management options before proceeding to antireflux interventions.
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Affiliation(s)
- L. Hillman
- Department of Medicine, Northwestern University Feinberg School of Medicine,
Chicago, IL, United States
| | - R. Yadlapati
- Division of Gastroenterology and Hepatology, Department of Medicine,
Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - A. J. Thuluvath
- Department of Medicine, Johns Hopkins Bayview Medical Center, Baltimore,
Maryland, USA
| | - M. A. Berendsen
- Galter Health Sciences Library, Northwestern University Feinberg School of
Medicine, Chicago, Illinois
| | - J. E. Pandolfino
- Division of Gastroenterology and Hepatology, Department of Medicine,
Northwestern University Feinberg School of Medicine, Chicago, IL, United States
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8
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Hillman L, Yadlapati R, Thuluvath AJ, Berendsen MA, Pandolfino JE. A review of medical therapy for proton pump inhibitor nonresponsive gastroesophageal reflux disease. Dis Esophagus 2017. [PMID: 28859358 DOI: 10.1093/dote/dox055.pmid:28859358;pmcid:pmc5788178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
Abstract
Up to 40% of patients report persistent gastroesophageal reflux disease (GERD) symptoms despite proton pump inhibitor (PPI) therapy. This review outlines the evidence for medical therapy for PPI nonresponsive GERD. A literature search for GERD therapies from 2005 to 2015 in PubMed, EMBASE, Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews identified 2928 unique citations. Of those, 40 unique articles specific to the impact of PPI metabolizer genotype on PPI response and the use adjunctive medical therapies were identified. Thirteen articles reported impacts on CYP genotypes on PPI metabolism demonstrating lower endoscopic healing rates in extensive metabolizers; however, outcomes across genotypes were more uniform with more CYP independent PPIs rabeprazole and esomeprazole. Twenty-seven publications on 11 adjunctive medications showed mixed results for adjunctive therapies including nocturnal histamine-2 receptor antagonists, promotility agents, transient lower esophageal sphincter relaxation inhibitors, and mucosal protective agents. Utilizing PPI metabolizer genotype or switching to a CYP2C19 independent PPI is a simple and conservative measure that may be useful in the setting of incomplete acid suppression. The use of adjunctive medications can be considered particularly when the physiologic mechanism for PPI nonresponse is suspected. Future studies using adjunctive medications with improved study design and patient enrollment are needed to better delineate medical management options before proceeding to antireflux interventions.
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Affiliation(s)
- L Hillman
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - R Yadlapati
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - A J Thuluvath
- Department of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA
| | - M A Berendsen
- Galter Health Sciences Library, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - J E Pandolfino
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
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Refractory chronic cough due to gastroesophageal reflux: Definition, mechanism and management. World J Methodol 2015; 5:149-56. [PMID: 26413488 PMCID: PMC4572028 DOI: 10.5662/wjm.v5.i3.149] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Revised: 07/06/2015] [Accepted: 07/11/2015] [Indexed: 02/06/2023] Open
Abstract
Refractory chronic cough due to gastroesophageal reflux is a troublesome condition unresponsive to the standard medical anti-reflux therapy. Its underlying mechanisms may include incomplete acid suppression, non-acid reflux, transient lower esophageal sphincter relaxations and esophageal hypersensitivity. The diagnosis of this disorder depends on both the findings of multi-channel intraluminal impedance-pH monitoring and the subsequent intensified anti-reflux therapy. The strategies of pharmacological treatment for refractory chronic cough due to reflux include the optimization of proton pump inhibitors and add-on therapies with histamine H2 receptor antagonists, baclofen and gabapentin. However, the further study is needed to satisfy its management.
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Richter JE. Current Diagnosis and Management of Suspected Reflux Symptoms Refractory to Proton Pump Inhibitor Therapy. Gastroenterol Hepatol (N Y) 2014; 10:547-555. [PMID: 27551249 PMCID: PMC4991531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Suspected reflux symptoms that are refractory to proton pump inhibitors (PPIs) are rapidly becoming the most common presentation of gastroesophageal reflux disease (GERD) in patients seen in gastroenterology clinics. These patients are a heterogeneous group, differing in symptom frequency and severity, PPI dosing regimens, and responses to therapy (from partial to absent). Before testing, the physician needs to question the patient carefully about PPI compliance and the timing of drug intake in relation to meals. Switching PPIs or doubling the dose is the next step, but only 20% to 25% of the group refractory to PPIs will respond. The first diagnostic test should be upper gastrointestinal endoscopy. In more than 90% of cases, the results will be normal, but persistent esophagitis may suggest pill esophagitis, eosinophilic esophagitis, or rarer diseases, such as lichen planus, Zollinger-Ellison syndrome, or genotype variants of PPI metabolism. If the endoscopy results are normal, esophageal manometry and especially reflux testing should follow. Whether patients should be tested on or off PPI therapy is controversial. Most physicians prefer to test patients off PPIs to identify whether abnormal acid reflux is even present; if it is not, PPIs can be stopped and other diagnoses sought. Testing patients on PPI therapy allows nonacid reflux to be identified, but more than 50% of patients have a normal test result, leaving the clinician with a conundrum-whether to stop PPIs or continue them because the GERD is being treated adequately. Alternative diagnoses in patients with refractory GERD and normal reflux testing include achalasia, eosinophilic esophagitis, gastroparesis, rumination, and aerophagia. However, more than 50% will be given the diagnosis of functional heartburn, a visceral hypersensitivity syndrome. Treating patients with PPI-refractory GERD-like symptoms can be difficult and frustrating. Any of the following may help: a histamine-2 receptor antagonist at night, baclofen to decrease transient lower esophageal sphincter relaxations, pain modulators, acupuncture, or hypnotherapy. At this time, antireflux surgery should be limited to patients with abnormal acid reflux defined by pH testing and a good correlation of symptoms with acid reflux.
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Affiliation(s)
- Joel E Richter
- Dr Richter is a professor of medicine, the Hugh F. Culverhouse Chair for Esophagology, director of the Division of Digestive Diseases and Nutrition, and director of the Joy McCann Culverhouse Center for Swallowing Disorders at the University of South Florida Morsani College of Medicine in Tampa, Florida
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11
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Systematic review of patient-reported outcome instruments for gastroesophageal reflux disease symptoms. Eur J Gastroenterol Hepatol 2013. [PMID: 23202695 DOI: 10.1097/meg.0b013e328358bf74] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Gastroesophageal reflux disease (GERD) symptoms are best assessed using patient-reported outcome (PRO) instruments. Guidance on developing well-defined and reliable instruments that capture optimal information from the patient's perspective was recently published by the US Food and Drug Administration and the European Medicines Agency. The aim of this systematic review was to identify and evaluate existing PRO instruments for GERD symptoms with regard to regulatory requirements. Systematic literature searches were conducted in PubMed and Embase to identify PRO instruments for GERD symptoms that have undergone psychometric evaluation. Content, construct and test-retest reliability, internal consistency, and responsiveness were evaluated in relation to regulatory recommendations. Supplementary searches were conducted to assess whether identified instruments had been used as clinical trial endpoint measures. The systematic literature searches identified 15 PRO instruments for GERD symptoms that have undergone psychometric evaluation. Eight were designed to evaluate GERD symptoms, two were to diagnose GERD, four were designed for both evaluative and diagnostic purposes, and one was designed for screening purposes. Five instruments were developed and reported to include most steps recommended by the Food and Drug Administration and European Medicines Agency, and have also been used as endpoint measures in clinical trials: the GERD Symptom Assessment Scale, the Nocturnal Gastro-oesophageal Reflux Disease Symptom Severity and Impact Questionnaire, the Reflux Questionnaire, the Reflux Disease Questionnaire, and the Proton pump inhibitor Acid Suppression Symptom test. Existing PRO instruments for GERD do not meet all the regulatory requirements for an outcome instrument in reflux trials and may need further validation.
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12
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Gawron AJ, Rothe J, Fought AJ, Fareeduddin A, Toto E, Boris L, Kahrilas PJ, Pandolfino JE. Many patients continue using proton pump inhibitors after negative results from tests for reflux disease. Clin Gastroenterol Hepatol 2012; 10:620-5; quiz e57. [PMID: 22366177 PMCID: PMC3547497 DOI: 10.1016/j.cgh.2012.02.012] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2011] [Revised: 01/09/2012] [Accepted: 02/02/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Ambulatory reflux testing is used to evaluate symptoms of gastroesophageal reflux disease (GERD) refractory to protein pump inhibitors (PPIs). We investigated the prevalence of PPI use in patients with negative results from Bravo pH or multichannel intraluminal impedance-pH (MII-pH) tests and factors that might predict the use of PPIs. METHODS We analyzed data from patients who had undergone Bravo pH monitoring or MII-pH testing at Northwestern University, without evidence of reflux disease. Demographics, endoscopy findings, pathology results, and provider recommendations were obtained via chart review. Eligible patients (n = 90) were contacted by telephone, and a cross-sectional survey was administered with questions about symptom severity, demographics, medication use, and health behaviors. Patients were compared by current PPI use, and statistical analyses were performed by using SAS version 9.2 software. RESULTS Thirty-eight patients (42.2%) reported current PPI use despite a negative result from a pH study. Only 17 patients (18.9%) recalled being instructed to stop taking PPIs; chart review showed documented instructions to stop PPI therapy for 15 patients (16.7%). There were no significant differences in demographic or clinical characteristics among patients compared by current PPI use. Patients taking a PPI were more likely than those not taking a PPI to report troublesome symptoms that affected their daily life, as measured by a questionnaire for the diagnosis of GERD (the GerdQ). CONCLUSIONS More than 42% of patients with negative results from pH monitoring studies continue PPI therapy despite physiological data that they do not have GERD.
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Affiliation(s)
- Andrew J Gawron
- Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois 60611, USA
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Shin JM, Inatomi N, Munson K, Strugatsky D, Tokhtaeva E, Vagin O, Sachs G. Characterization of a novel potassium-competitive acid blocker of the gastric H,K-ATPase, 1-[5-(2-fluorophenyl)-1-(pyridin-3-ylsulfonyl)-1H-pyrrol-3-yl]-N-methylmethanamine monofumarate (TAK-438). J Pharmacol Exp Ther 2011; 339:412-20. [PMID: 21828261 DOI: 10.1124/jpet.111.185314] [Citation(s) in RCA: 104] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Inhibition of the gastric H,K-ATPase by the potassium-competitive acid blocker (P-CAB) 1-[5-(2-fluorophenyl)-1-(pyridin-3-ylsulfonyl)-1H-pyrrol-3-yl]-N-methylmethanamine (TAK-438), is strictly K(+)-competitive with a K(i) of 10 nM at pH 7. In contrast to previous P-CABs, this structure has a point positive charge (pK(a) 9.06) allowing for greater accumulation in parietal cells compared with previous P-CABs [e.g., (8-benzyloxy-2-methyl-imidazo(1,2-a)pyridin-3-yl)acetonitrile (SCH28080), pK(a) 5.6]. The dissociation rate of the compound from the isolated ATPase is slower than other P-CABs, with the t(1/2) being 7.5 h in 20 mM KCl at pH 7. The stoichiometry of binding of TAK-438 to the H,K-ATPase is 2.2 nmol/mg in the presence of Mg-ATP, vanadate, or MgP(i). However, TAK-438 also binds enzyme at 1.3 nmol/mg in the absence of Mg(2+). Modeling of the H,K-ATPase to the homologous Na,K-ATPase predicts a close approach and hydrogen bonding between the positively charged N-methylamino group and the negatively charged Glu795 in the K(+)-binding site in contrast to the planar diffuse positive charge of previous P-CABs. This probably accounts for the slow dissociation and high affinity. The model also predicts hydrogen bonding between the hydroxyl of Tyr799 and the oxygens of the sulfonyl group of TAK-438. A Tyr799Phe mutation resulted in a 3-fold increase of the dissociation rate, showing that this hydrogen bonding also contributes to the slow dissociation rate. Hence, this K(+)-competitive inhibitor of the gastric H,K-ATPase should provide longer-lasting inhibition of gastric acid secretion compared with previous drugs of this class.
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Affiliation(s)
- Jai Moo Shin
- Department of Physiology and Medicine, David Geffen School of Medicine, University of California at Los Angeles, and VA Greater Los Angeles Healthcare System, Los Angeles, 11301 Wilshire Blvd., Bldg. 113, CA 90073, USA.
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Peura DA, Berardi RR, Gonzalez J, Brunetti L. The value of branded proton pump inhibitors: formulary considerations. P & T : A PEER-REVIEWED JOURNAL FOR FORMULARY MANAGEMENT 2011; 36:434-45. [PMID: 21931475 PMCID: PMC3171810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Accepted: 03/07/2011] [Indexed: 05/31/2023]
Abstract
The prevalence of gastroesophageal reflux disease (GERD) continues to rise, placing an increasing burden on our health care system. Proton pump inhibitors (PPIs) are the most effective and widely used therapy for GERD. Many PPIs are now available in generic and over-the-counter forms, and managed care formularies often choose these as their preferred drug for GERD treatment. However, newer-generation branded PPIs, as a result of differences in their pharmacokinetic and pharmacodynamic profiles, may offer clinical advantages over generic PPIs. This article discusses these differences and the advantages they offer and suggests possible ways to incorporate the newer PPIs into formularies.
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Rakesh TP. Proton pump inhibitors: use, misuse and concerns about long-term therapy. Clin J Gastroenterol 2011; 4:53-9. [DOI: 10.1007/s12328-011-0208-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2010] [Accepted: 01/19/2011] [Indexed: 02/07/2023]
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Hoogendoorn RJ, Groeneveld L, Kwee JA. Patient Satisfaction with Switching to Esomeprazole from Existing Proton Pump Inhibitor Therapy for Gastro-Oesophageal Reflux Disease. Clin Drug Investig 2009; 29:803-10. [DOI: 10.2165/11530810-000000000-00000] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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