PPI-Refractory GERD a Common Problem

Sean Delshad, MD

New data points to a major problem for patients with gastroesophageal reflux disease (GERD) where symptoms do not improve despite treatment.

A research team, led by Sean D. Delshad, MD, Cedars-Sinai Center for Outcomes Research and Education (CS-CORE), performed a population-based study to determine the prevalence of GERD symptoms and persistent GERD symptoms despite the use of proton pump inhibitors (PPIs).

“Using a population-based survey, we found GERD symptoms to be common: 2 of 5 participants have had GERD symptoms in the past and 1 of 3 had symptoms in the last week,” the authors wrote. “We also found that half of PPI users have persistent symptoms.”

GERD is an extremely common issue, especially in western countries. It’s estimated that approximately 20% of adults in the US suffer from GERD. Despite 40% of patients with GERD using protein pump inhibitors, the majority still have symptoms of reflux disease.

The investigators conducted the National Gastrointestinal Survey in 2015 using MyGiHealth, a mobile application that guides participants through National Institutes of Health gastrointestinal PROMIS surveys.

The primary outcomes in the study were the prevalence of GERD symptoms in the past and persistence of GERD symptoms (heartburn or regurgitation 2 or more days in past week) among participants taking PPIs.

They also applied population weights to the data and performed multivariable regression to adjust for confounding.

The study included 71,812 participants, with 32,878 (44.1%) reported having had GERD symptoms in the past and 23,039 (30.9%) reported having GERD symptoms in the last week.

They also found that 35.1% of patients who experienced GERD symptoms were currently on therapy (55.2% on PPIs, 24.3% on histamine-2 receptor blockers, and 24.4% on antacids).

For the 3229 patients taking daily PPIs, 54.1% had persistent GERD symptoms.

They found certain trends along demographical lines, where younger individuals, women, Latinos, and participants with irritable bowel syndrome or Crohn’s disease were more likely to have continued symptoms, even when taking PPIs.

The investigators suggest further studies are needed to develop new therapies for patients with PPI-refractory GERD symptoms.

Recently, a team of investigators, led by Stuart J. Spechler, MD, Baylor Scott & White Health, examined the success rate between treating PPI-refractory heartburn with medication, surgery, or a placebo.

The study included 78 patients referred to Veterans Affairs gastroenterology clinics for PPI-refractory heartburn. Patients with persistent heartburn underwent endoscopy, esophageal biopsy, esophageal manometry, and multichannel intraluminal impedance-pH monitoring.

The patients found to have reflux-related heartburn were randomly assigned to receive either a surgical treatment (laparoscopic Nissen fundoplication), active medical treatment (omeprazole plus baclofen, with desipramine added depending on symptoms), or control medical treatment (omeprazole plus placebo).

The primary outcome of the study was treatment success, defined as a decrease of 50% or more in the Gastroesophageal Reflux Disease (GERD)—Health Related Quality of Life score at 1 year.

The incidence of treatment success with surgery was 18 of the 27 patients (67%), which was significantly higher than the medical treatment group, which was 7 of 25 (28% P =.007) or control medical treatment, which was 3 of 26 patients (12%; P <.001).

The difference in the incidence of treatment success between the active medical group and the control medical group was 16 percentage points (95% CI,−5-38; P =.17).

In the study, each patient was given 20 mg of omeprazole twice a day taken about 30 minutes before meals.

The study, “Prevalence of Gastroesophageal Reflux Disease and Proton Pump Inhibitor-Refractory Symptoms,” was published online in Gastroenterology.