Reviews for Primary Care - Fall 2007 - (Page 57) GERD Symptoms on Antisecretory Therapy One study examined the effect of ranitidine 150 mg HS compared to placebo in patients on once-daily PPI who had continued nighttime symptoms. No difference was seen in overall efficacy between the 2 groups.22 Therefore, I only use this approach when continued symptoms are intermittent and/or the patient can clearly delineate when he or she is going to have nighttime symptoms. The asneeded use of H2RA seems to be best in this clinical scenario. Some would debate what I believe is a reasonable decision to perform endoscopy, which in this case, reveals low-grade erosive esophagitis and a “short segment” of columnar-lined esophagus (which on biopsy has the classic features of Barrett’s metaplasia). Prolonged pH (reflux) monitoring is listed as one of the potential interventions; however, I believe this is premature given the presentation and definite improvement in initial symptoms. Had the patient exhibited NO response to once-daily PPI, one might move directly to pH studies to document the presence or absence of abnormal esophageal acid exposure and save a prolonged therapeutic trial. Healing of erosive esophagitis is perhaps the most objective way to assess therapeutic efficacy of PPIs. In the meta-analysis cited previously, a mean of 83.6% ( 11.4%) of patients with erosive esophagitis healed with PPI therapy, with an effective healing rate of 11.7% ( 0.5%) per week.6 Four large, 8-week healing trials comparing esomeprazole 40 mg to omeprazole, lansoprazole, and pantoprazole (20, 30, and 40 mg, respectively) showed overall healing rates of 84% to 95% (Figure 2).1-4 Differences in healing rates by grade are evident with decrease in healing with the higher grades (C and D) (Figure 3).1-5 These patients are among the most severely affected of the population of GERD patients, likely having the greatest 100 86.9 Patients healed (%) 80 60 40 20 0 94.1 84.2 93.7 88.8 92.6 92.1 95.5 Kahrilas (N 1304) Richter (N 2425) Castell (N 5241) Labenz (N 3161) 8 weeks Omeprazole 20 mg qd Lansoprazole 30 mg qd Esomeprazole 40 mg qd Pantoprazole 40 mg qd Figure 2. Healing rates for all grades of erosive esophagitis at 8 weeks from 4 large, randomized, controlled trials. Despite excellent results with all of the drugs illustrated, some patients are not healed at 8 weeks. Data from Richter JE et al,1 Kahrilas PJ et al,2 Castell DO et al,3 and Labenz J et al.4 esophageal acid exposure, particularly at night. As examination of these studies indicates, somewhere between 5% and 15% of all patients with erosive esophagitis would be unhealed at the 8-week time frame. If we accept conservatively that 40% of patients with heartburn more than 3 times a week will have erosive esophagitis, then somewhere between 2% and 9% of all patients treated with PPIs would remain unhealed after 8 weeks of empiric therapy. If we include those with Barrett’s esophagus, an additional group of patients will have an abnormal endoscopy. Although this number is only a crude estimate, it puts in perspective the potential for finding ero- Figure 3. Healing of Los Angeles Grade C & D esophagitis, illustrating that an important percentage will not heal after 8 weeks of once-daily PPI. Data from Richter JE et al,1 Kahrilas PJ et al,2 Castell DO et al,3 Labenz J et al,4 and Fennerty MB et al.5 100 87.3 Healed at 8 weeks (%) 80 60 40 20 0 1 2 3 4 Study, by reference number 68.3 83.0 74.0 87.0 74.3 77.5 73.3 90.7 84.3 5 Omeprazole 20 mg daily Lansoprazole 30 mg daily Esomeprazole 40 mg daily Pantoprazole 40 mg daily VOL. 1 NO. 1 2007 REVIEWS FOR PRIMARY CARE 57
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