The proton pump inhibitor test for gastroesophageal reflux disease: Optimal cut-off value and duration

Leone, Annalisa de; Tonini, Marcello; Dominici, P; Grossi, Enzo; Pace, F.

doi:10.1016/j.dld.2010.04.002

Cited by 20 publications

(14 citation statements)

References 36 publications

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“…This indicates that a short follow‐up in the clinical setting is sufficient to estimate whether a patient will respond symptomatically to a PPI, and prolonging of the same treatment regimen in non‐responders would be of limited value. This rapid response is in accordance with a previously calculated optimal cut‐off value to assess symptomatic response to PPI of 1 week 89 . A similar inference for research purposes could be that a follow‐up of 4 weeks in clinical trials should be sufficient to observe a treatment effect, if present.…”

Section: Discussionsupporting

confidence: 86%

PPI therapy is equally effective in well‐defined non‐erosive reflux disease and in reflux esophagitis: a meta‐analysis

Weijenborg

Cremonini

Smout

et al. 2012

Neurogastroenterology Motil

133

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Background Symptomatic response to proton pump inhibitor (PPI) therapy in patients with non-erosive reflux disease (NERD) is often reported as lower than in patients with erosive reflux disease (ERD). However, the definition of NERD differs across clinical trials. This meta-analysis aims to estimate the rate of symptom relief in response to PPI in NERD patients. Methods MEDLINE (1966, Cochrane Comprehensive Trial Register (1997 and EMBASE (1985EMBASE ( -2010 databases were searched and manual searches from studies' references were performed. Randomized clinical trials were selected that included patients with heartburn, and analyzed the effect of short-term PPI treatment. The primary outcome of selected studies was defined as complete or partial heartburn relief. Two reviewers independently extracted data and assessed study quality of selected articles. Random effects models and meta-regression were used to combine and analyze results. Key Results The pooled estimate of complete relief of heartburn after 4 weeks of PPI therapy in patients with ERD was 0.72 (95% CI 0.69-0.74) (32 studies), vs 0.50 (0.43-0.57) (eight studies) in empirically treated patients, 0.49 (0.44-0.55) (12 studies) in patients defined as non-erosive by negative endoscopy, and 0.73 (0.69-0.77) (two studies) in patients defined as non-erosive by both negative endoscopy and a positive pH-test. Conclusions & Inferences In well-defined NERD patients, the estimated complete symptom response rate after PPI therapy is comparable to the response rate in patients with ERD. The previously reported low response rate in studies with patients classified as NERD is likely the result of inclusion of patients with upper gastrointestinal symptoms that do not have reflux disease.

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Section: Discussionsupporting

confidence: 86%

PPI therapy is equally effective in well‐defined non‐erosive reflux disease and in reflux esophagitis: a meta‐analysis

Weijenborg

Cremonini

Smout

et al. 2012

Neurogastroenterology Motil

133

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“…However, the symptom improvement has been assessed by means of the validated GIS questionnaire and a VAS scale, and we used a symptom relief >75% to include patients in the study. In a previous study, this latter outcome measure has been considered the most useful cut‐off value to define a positive response to PPI test, allowing the maximal specificity value . Moreover, we are aware that MII‐pH test presents further limitation in predicting PPI response in particular in patients with a long‐life history of PPI‐sensitivity/refractoriness .…”

Section: Discussionmentioning

confidence: 99%

“…Gastroesophageal reflux disease impact scale comprises eight questions about the frequency, over the previous 2 weeks, of the following items: acid‐related symptoms; chest pain; extra‐esophageal symptoms; impact of symptoms on sleep, work, meals and social occasions; use of additional non‐prescription medications. Four response options were allowed to describe the frequency of the above items over the previous 2 weeks: ‘none of the time’, ‘a little of the time’, ‘some of the time’ and ‘all of the time’ . Patients were also asked to rate their satisfaction with symptom control on a global VAS from 0 (no relief at all) to 100 (complete symptom relief).…”

Section: Methodsmentioning

confidence: 99%

“…Consistently with this assumption, empiric acid suppression therapy with proton pump inhibitors (PPIs) is considered the mainstay of therapy for GERD patients and it is contemporarily used to determine whether upper gastrointestinal symptoms are acid related. In clinical practice, the well‐known PPI test measures the symptomatic response to PPI treatment administered for 14 days in patients with typical reflux symptoms, showing a high sensitivity but a poor specificity in detecting GERD …”

Section: Introductionmentioning

confidence: 99%

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Proton pump inhibitor responders who are not confirmed as GERD patients with impedance and pH monitoring: who are they?

Bortoli

Martinucci

Savarino

et al. 2013

Neurogastroenterology Motil

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“… 17 A major limitation of the ‘PPI test’ is the strong modulation of symptoms by oesophageal hypersensitivity 18 19 ; there is also variation in PPI dosing and duration of the test. 20 Nonetheless, despite low specificity and high placebo response, 21 the empiric PPI treatment approach is less costly than diagnostic testing 22 and is endorsed by societal guidelines 4 undoubtedly leading to the overdiagnosis of GERD and overuse of PPIs.…”

Section: Diagnosis Of Gerdmentioning

confidence: 99%

Modern diagnosis of GERD: the Lyon Consensus

Gyawali

Kahrilas

Savarino

et al. 2018

Gut

1,162

1,293

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Clinical history, questionnaire data and response to antisecretory therapy are insufficient to make a conclusive diagnosis of GERD in isolation, but are of value in determining need for further investigation. Conclusive evidence for reflux on oesophageal testing include advanced grade erosive oesophagitis (LA grades C and D), long-segment Barrett’s mucosa or peptic strictures on endoscopy or distal oesophageal acid exposure time (AET) >6% on ambulatory pH or pH-impedance monitoring. A normal endoscopy does not exclude GERD, but provides supportive evidence refuting GERD in conjunction with distal AET <4% and <40 reflux episodes on pH-impedance monitoring off proton pump inhibitors. Reflux-symptom association on ambulatory reflux monitoring provides supportive evidence for reflux triggered symptoms, and may predict a better treatment outcome when present. When endoscopy and pH or pH-impedance monitoring are inconclusive, adjunctive evidence from biopsy findings (histopathology scores, dilated intercellular spaces), motor evaluation (hypotensive lower oesophageal sphincter, hiatus hernia and oesophageal body hypomotility on high-resolution manometry) and novel impedance metrics (baseline impedance, postreflux swallow-induced peristaltic wave index) can add confidence for a GERD diagnosis; however, diagnosis cannot be based on these findings alone. An assessment of anatomy, motor function, reflux burden and symptomatic phenotype will therefore help direct management. Future GERD management strategies should focus on defining individual patient phenotypes based on the level of refluxate exposure, mechanism of reflux, efficacy of clearance, underlying anatomy of the oesophagogastric junction and psychometrics defining symptomatic presentations.

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The proton pump inhibitor test for gastroesophageal reflux disease: Optimal cut-off value and duration

Cited by 20 publications

References 36 publications

PPI therapy is equally effective in well‐defined non‐erosive reflux disease and in reflux esophagitis: a meta‐analysis

PPI therapy is equally effective in well‐defined non‐erosive reflux disease and in reflux esophagitis: a meta‐analysis

Proton pump inhibitor responders who are not confirmed as GERD patients with impedance and pH monitoring: who are they?

Modern diagnosis of GERD: the Lyon Consensus

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