ACG: GERD Patients on PPIs Still Have Reflux

PHILADELPHIA, Oct. 16 -- Most patients with gastroesophageal reflux disease continue to have reflux despite twice-daily dosing with a proton pump inhibitor, according to results of a study reported here.

But most of the episodes of reflux are non-acidic, Donald Castell, M.D., of the Medical University of South Carolina in Charleston, told attendees at the American College of Gastroenterology meeting.

"The acid is under control, but patients continue to have reflux," said Dr. Castell. "Physicians need to expand treatment to address the reflux."

Giving patients a drug such as baclofen or metoclopramide, in addition to the PPI, would be one way to manage continued non-acid reflux, he added.

Some gastroenterologists favor an increase in the upper limit of normal for 24-hour reflux episodes to define patients with persistent reflux despite acid suppression therapy, said Dr. Castell.

Development of 24-hour multichannel intraluminal impedance and pH (MII-pH) esophageal monitoring has given physicians the means to detect both acid (pH<4) and non-acid reflux episodes. Dr. Castell and colleagues employed MII-pH to evaluate the total number of reflux episodes (acid and non-acid) in GERD patients treated with different PPIs.

The study involved 167 patients who underwent MII-pH studies while on twice-daily PPI therapy. Drugs represented in the study were esomeprazole (Nexium), omeprazole (Prilosec and others), lansoprazole (Prevacid), rabeprazole (Aciphex), and pantoprazole (Protonix).

The mean number of non-acid reflux episodes during 24-monitoring ranged from 34 to 37 across the different drugs, and the number of acid episodes averaged five to 10 per 24 hours (P<0.05 versus non-acid reflux).

Using the criterion of 48 reflux episodes to define abnormal reflux, Dr. Castell found that 22% to 50% of patients had abnormal findings, and the proportion of patients with abnormal reflux did not differ significantly among the PPIs.

"Reflux continued to occur, and it didn't make any difference which PPI a patient was taking," said Dr. Castell. "However, the reflux was three to four times more likely to be non-acid than acid."