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PPIs and early heartburn relief

 

Clinical bottom line


Reference

KR McQuaid, L Laine. Early heartburn relief with proton pump inhibitors: a systematic review and meta-analysis of clinical trials. Clinical Gastroenterology and Hepatology 2005 3: 553-563.


Systematic review

The systematic review sought clinical trials of trials of PPIs in patients with gastrooesophageal reflux disease providing information about heartburn relief in the first or second day of therapy. Searching of several databases was to ,id-2004. For inclusion, adult patients with acute heartburn, erosive oesophagitis, non-erosive reflux, or symptomatic reflux. Studies had to have heartburn and/or symptomatic reflux at enrolment, as well as statistical as provide data about the first day of therapy. Excluded studies were those with PPI for maintenance, or with intermittent or on-demand therapy.

Outcomes chosen were:

  1. Patients on day 1 with heartburn resolution over the whole 24 hour period
  2. Patients on day 1 with daytime resolution of symptoms
  3. Patients on day 1 with night-time resolution of symptoms
  4. Absence of heartburn on day 1 sustained for seven consecutive days

Results

The study found 17 articles with 18 trials. One was uncontrolled, and one not blinded, and these were omitted for the calculations below. Analysis in the review was not by drug or dose. The results in Table 1 for particular drug-dose combinations, and for the four outcomes, were recalculated from data provided. No statistical analysis has been attempted.

Table 1: Pooled percentage of patients with outcomes for each drug-dose combination with at least two trials

Number of
Drug and dose (mg)
Trials
Patients
Percent with outcome
24 hour heartburn relief
Esomeprazole 20
2
802
36
Esomeprazole 40
5
4771
34
Lansoprazole 30
3
4507
29
Omeprazole 20
4
3697
29
Daytime heartburn relief
Esomeprazole 40
2
1603
44
Lansoprazole 15
2
288
44
Lansoprazole 30
4
2098
46
Omeprazole 20
3
603
32
Omeprazole 40
2
207
33
Rabeprazole 20
2
185
38
Night-time heartburn relief
Esomeprazole 40
2
1603
46
Lansoprazole 15
2
288
52
Lansoprazole 30
4
2098
51
Omeprazole 20
3
603
43
Omeprazole 40
2
207
43
Rabeprazole 20
2
185
52
Sustained heartburn relief
Esomeprazole 20
3
860
19
Esomeprazole 40
5
3542
24
Lansoprazole 30
2
3216
20
Omeprazole 20
3
3579
24

 

PPIs were most effective at resolving night-time heartburn, then daytime heartburn. About a third of patients had 24-hour relief of symptoms on day 1, with about a fifth having relief on day 1 sustained over the following week. A small amount of information suggested that day 2 relief was somewhat better than day 1 relief.

Based on the large amount of information on some drug-dose combinations, esomeprazole 20 and 40 mg, and lansoprazole 30 mg seemed to be the best choice for early relief of heartburn.

Comment

This is a useful review. Oral PPIs achieve maximal acid suppression over about four days, and it is therefore interesting to know what efficacy for heartburn symptoms might be expected within the first or second day. The review demonstrates that a significant proportion of patients have a meaningful level of relief quite quickly. The review also tells us where the bulk of the evidence is, for particular drug-dose combinations, and allows choice to be based on additional evidence than long-term relief.