Who Responds to PPIs?

A group of German researchers investigated predictors of which patients with gastroesophageal reflux disease symptoms were most likely to respond to proton pump inhibitors.

For the 40% of Americans who have gastroesophageal reflux disease (GERD) symptoms, relief can be as simple as taking a daily proton pump inhibitor (PPI). For many patients, however, recommended doses of PPIs don’t provide complete relief. Many causes have been associated with PPI failure, and some patients have multiple complicating pathologies. Upper endoscopy appears to have limited diagnostic value in PPI-refractory patients. Recently, studies have suggested esophageal impedance with pH testing can provide insight that helps manage the most challenging patients.

A team of German researchers focused on identifying predictors that would increase the likelihood of diagnosing GERD reliably and predict who will respond to PPIs. Their results appear in the April 14, 2014, issue of World Journal of Gastroenterology. In this retrospective study, the researchers analyzed 683 consecutive patients with a suspected GERD diagnosis. All patients underwent pH-metry/impedance measurement (pH/MII) and had previously been prescribed pantoprazole 40 mg/day or a comparable PPI regimen.

The researchers defined two groups of patients. The 466 patients in Group A had discontinued PPI therapy for at least 10 days before undergoing pH/MII. The 223 patients in Group’s B continued their prescribed PPI therapy and had pH/MII. All patients completed symptom- and lifestyle-based questionnaires.

In group A, patients who had typical GERD symptoms (heartburn and regurgitation), a positive symptom index, and pathological results in pH/MII along with atypical symptoms including hoarseness and fullness were most likely to respond to empiric PPI trials. Patients who had positive symptom index and heartburn and regurgitation or were male or obese were most likely to have pathological results in pH/MII.

Patients in group B who consumed alcohol regularly were most likely to respond to PPIs. In group B patients, a positive symptom index and vomiting also predicted successful PPI treatment, but the researchers noted it was more difficult to tease out objective and subjective predictors of successful PPI treatment or pathology. In this group, they suggest that functional disease may be more prevalent.

The researchers concluded that sex, obesity, and alcohol intake can predict PPI responses. In particular, they noted that clinicians who see non-obese female patients with non-typical reflux symptoms should consider pH/MII instead of empiric PPI trials.

Ms. Wick is a visiting professor at the University of Connecticut School of Pharmacy and a freelance writer from Virginia.