Clinical and pathophysiological consequences of on-demand treatment with PPI in endoscopy-negative reflux disease. Is rebound hypersecretion of acid a problem?

OBJECTIVE: Rebound acid hypersecretion after withdrawal of proton pump inhibitor (PPI) may lead to symptom aggravation and difficulties in withdrawing anti-reflux medication. The aim was to investigate pathophysiological and clinical consequences of on-demand treatment with PPI in patients with endoscopy-negative reflux disease. MATERIAL AND METHODS: Twenty-six patients with endoscopy-negative reflux disease were investigated for rebound effects of lansoprazole 15 mg, used on-demand, maximum 4 capsules daily during a 6-month period. P-CgA and s-gastrin were measured before, at termination and 2 weeks after stopping treatment. Symptom score was performed the week before and the second week after treatment, 24-h pH-metry after both periods. RESULTS: Median daily consumption of lansoprazole was 15.1 mg (95% CI: 10.5; 18.8). S-gastrin before treatment was 31.2 pmol/l, 54.8 at the end (p < 0.01), 31.7 two weeks after withdrawal. P-CgA was 16.7 u/l before treatment, 37.5 at the end (p < 0.01), 17.7 two weeks after withdrawal (p = 0.35). A positive correlation was found between total consumption of lansoprazole and CgA increase during treatment (r = 0.44 p = 0.03). There was a reduction in symptom score during the treatment period from 30 (24-38) before, to 20 (15-36) the second week after treatment, p = 0.06. 32% had increase in symptoms. CONCLUSIONS: Rebound acid hypersecretion is probably an infrequent problem in on-demand treatment with PPI in patients with endoscopy-negative reflux disease. A significant increase in p-CgA and s-gastrin was found after 6 months treatment. Fourteen days after withdrawal, CgA and gastrin returned to pretreatment levels. Overall, no aggravation of symptoms was found, but 1/3 experienced increased symptoms.

On-demand PPI requirements in patients with endoscopy-negative GERD.

GOALS: To evaluate the need for on-demand treatment with proton pump inhibitor in patients with endoscopy-negative GERD. BACKGROUND: Studies indicate that on-demand therapy is suitable for patients without mucosal disease, but the need for PPI in a monotherapy situation is not known. STUDY: Forty-one patients with heartburn and/or acid reflux of more than 3 months duration participated in the study. All were endoscopy-negative and had responded positive to a test with lansoprazole 60 mg x 1 for 7 days. Twenty-four hour pH monitoring was attempted in all, but failed in 4. Twenty-eight had pH <4 more than 4% of the time, 9 had less. During a 3-month period, the patients were allowed to take 1 capsule 30 mg lansoprazole on-demand, maximum 2 capsules a day. The remaining capsules were counted monthly. RESULTS: In the 3-month period, the median mean daily consumption was 1.06 capsule (95% CI: 0072-1.09). No significant difference was found between those with normal or abnormal 24-hour pH-metry. Sixty-three percent used 6 or more capsules a week. CONCLUSION: Patients with longstanding negative-endoscopy reflux disease, whether abnormal or normal 24-hour pH-metry, have symptoms that demand effective therapy. Using PPI on-demand as monotherapy, most patients will need 1 capsule per day.