Pantoprazole 40 mg is as effective as esomeprazole 40 mg to relieve symptoms of gastroesophageal reflux disease after 4 weeks of treatment and superior regarding the prevention of symptomatic relapse

Pantoprazole: a proton pump inhibitor

Pantoprazole is a proton pump inhibitor (PPI) that binds irreversibly and specifically to the proton pump, thereby reducing gastric acid secretion. Pantoprazole has a relatively long duration of action compared with other PPIs, and a lower propensity to become activated in slightly acidic body compartments. To date, no drug-drug interactions have been identified with pantoprazole in numerous interaction studies. Overall, in the short-term (8-10 weeks) initial treatment of gastro-oesophageal reflux disease (a condition that occurs when the reflux of gastric contents causes troublesome symptoms and/or complications) and long-term (6-24 months) maintenance therapy, oral pantoprazole 20 or 40 mg/day demonstrated similar efficacy to omeprazole, lansoprazole and esomeprazole and greater efficacy than histamine type 2 receptor antagonists. Pantoprazole is also effective in treating and preventing NSAID-related gastric and gastroduodenal injury. The optimal adult oral dose for gastric acid-related disorders is pantoprazole 40 mg once daily. Although data are limited, pantoprazole 20 or 40 mg/day was effective and well tolerated in the treatment of acid-related disorders in children and adolescents. Pantoprazole was also well tolerated in adults with acid-related disorders in short- and long-term studies. Thus, pantoprazole is a valuable agent for the management of acid-related disorders.

An update on the use of pantoprazole as a treatment for gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is a chronic, recurrent disease that affects nearly 19 million people in the US. The mainstay of therapy for GERD is acid suppression. Proton pump inhibitors (PPIs) are the most effective medication for both initial treatment and maintenance therapy of GERD. Pantoprazole, a first-generation PPI, was approved by the FDA in 2000 for the treatment of erosive esophagitis associated with GERD. It has been used in more than 100 different countries worldwide. It is one of the few PPIs available in multiple forms: a delayed-release oral capsule, oral suspension, and intravenous. Pantoprazole been shown to improve acid reflux-related symptoms, heal esophagitis, and improve health-related quality of life more effectively than histamine-2 receptor antagonists. Evaluated in over 100 clinical trials, pantoprazole has an excellent safety profile, is as efficacious as other PPIs, and has a low incidence of drug interactions. It has also been shown to be safe and effective in special patient populations, such as the elderly and those with renal or moderate liver disease.

Impact of PPIs on patient focused symptomatology in GERD

About half of patients with gastroesophageal reflux disease (GERD) have a normal endoscopy, so symptom assessment is the only appropriate outcome measure for these persons. Symptom assessment is also of great importance in persons with erosive esophagitis. There is currently no fully validated questionnaire to compare symptom response to treatment of patients with GERD. The aim of this review is to consider ReQuest^™ assessment tool to evaluate esophageal, supra-esophageal, and infra-esophageal symptoms, as well as any modification of the patient’s quality of life. The ReQuest^™ may be combined with the Los Angeles classification of esophagitis (LA A–D), to include the normal endoscopic finding in normal endoscopy reflux disease. The ReQuest^™ score declines rapidly towards normal with patient treatment with a proton pump inhibitor. A proportion of patients need more than the usual 8 weeks of therapy. For example, in GERD patients with Los Angeles B–D, the ReQuest^™ score falls more with pantoprazole 40 mg than with esomoprazole 40 mg after 12 weeks of therapy. Now that the simplified ReQuest in Practice^™ is available, this validated brief questionnaire has potential as an instrument for use in GERD patients seen in everyday clinical practice.

Effect of increasing esomeprazole and pantoprazole doses on acid control in patients with symptoms of gastro-oesophageal reflux disease: a randomized, dose-response study

BACKGROUND AND OBJECTIVE

In patients with gastro-oesophageal reflux disease (GORD), dose escalation or drug switching may be considered in those with symptoms that persist despite standard-dose proton pump inhibitor (PPI) therapy. This study set out to assess whether increasing the dosage of oral esomeprazole and pantoprazole improves acid control in GORD patients, and to compare the pharmacodynamic efficacy of esomeprazole and pantoprazole administered at different dosages.

METHODS

This was an open-label, randomized, six-way crossover study that included Helicobacter pylori-negative GORD patients (aged 20-60 years) with <30% of time with intragastric pH>4. Patients were treated with oral once-daily esomeprazole 20 mg, 40 mg and 80 mg, and pantoprazole 20 mg, 40 mg and 80 mg, for 5 days. The main outcome measures were time with intragastric pH>4 over 24 hours, median pH over 24 hours and area under the hydrogen ion versus time curve on day 5 for each treatment period.

RESULTS

Dose escalation with both PPIs improved acid control. The proportion of time with intragastric pH>4 (day 5) was 46.7% with esomeprazole 20 mg/day, 58.6% with esomeprazole 40 mg/day, and 65.8% with esomeprazole 80 mg/day; the corresponding percentages with pantoprazole were 28.6%, 36.9% and 44.9%, respectively. On a milligram-per-milligram basis, esomeprazole provided greater acid control than pantoprazole (p<0.001).

CONCLUSION

Dose escalation with oral esomeprazole and pantoprazole improves acid control in patients with GORD, although esomeprazole provides significantly greater acid control on a milligram-per-milligram basis.

Long-term management of gastroesophageal reflux disease with pantoprazole

Gastroesophageal reflux disease (GERD) is a chronic, relapsing disease that can progress to major complications. Affected patients have poorer health-related quality of life than the general population. As GERD requires continued therapy to prevent relapse and complications, most patients with erosive esophagitis require long-term acid suppressive treatment. Thus GERD results in a significant cost burden and poor health-related quality of life. The effective treatment of GERD provides symptom resolution and high rates of remission in erosive esophagitis, lowers the incidence of GERD complications, improves health-related quality of life, and reduces the cost of this disease. Proton pump inhibitors are accepted as the most effective initial and maintenance treatment for GERD. Oral pantoprazole is a safe, well tolerated and effective initial and maintenance treatment for patients with nonerosive GERD or erosive esophagitis. Oral pantoprazole has greater efficacy than histamine H(2)-receptor antagonists and generally similar efficacy to other proton pump inhibitors for the initial and maintenance treatment of GERD. In addition, oral pantoprazole has been shown to improve the quality of life of patients with GERD and is associated with high levels of patient satisfaction with therapy. GERD appears to be more common and more severe in the elderly, and pantoprazole has shown to be an effective treatment for this at-risk population.

The Concept of Complete Remission of Gastro-Oesophageal Reflux Disease

Gastro-oesophageal reflux disease (GORD) is associated with a broad array of symptoms that may be typical or atypical of the disease and that may be accompanied by erosive oesophagitis. Symptom scales that have historically been employed to assess response to treatment in GORD clinical trials do not typically account for the heterogeneous, episodic nature of GORD and the poor correlation between patients' and physicians' assessment of symptoms. The ReQuest questionnaire permits self-assessment of changes on a broad range of GORD-related symptoms on a daily basis and in combination with the Los Angeles (LA)-classification (ReQuest/LA-classification) to assess complete remission of GORD. Pantoprazole and esomeprazole are two of the newer proton pump inhibitors and are the first to be systematically reviewed using the ReQuest(trade mark) questionnaire. Results from recent head-to-head trials have shown pantoprazole and esomeprazole to be highly and equally effective treatments for (i) rapid and sustained relief of ReQuest-assessed GORD-related symptoms in patients with non-erosive GORD or endoscopically confirmed erosive GORD, and (ii) achieving a combined outcome comprising endoscopically confirmed healing and ReQuest-assessed symptom relief in patients with erosive GORD. There is some preliminary evidence to suggest that pantoprazole may be the better choice of treatment in terms of its potential to maintain control of symptoms in patients for whom night-time symptoms are a concern and if taken as on-demand rather than continuous maintenance therapy.