Wireless reflux monitoring could help determine which patients with reflux symptoms can safely discontinue proton-pump inhibitor (PPI) therapy, a recent study found.
The two-center trial included 100 adults with troublesome esophageal symptoms of heartburn, regurgitation, and/or chest pain, and inadequate PPI response. The participants stopped their PPIs for three weeks. A week after discontinuation, they had a wireless pH capsule placed during sedated upper GI endoscopy and then underwent 96 hours of wireless reflux monitoring. The primary outcome was tolerance of PPI cessation. Symptoms were measured by the Reflux Symptom Questionnaire electronic Diary (RESQ-eD). The results were published by Gastroenterology on Sept. 16.
Thirty-four participants discontinued their PPIs after the intervention. The study found a strong association between patients' acid exposure time (AET), measured by the wireless capsule, and their need to resume PPI. The strongest predictor of PPI discontinuation was number of days with more than 4.0% AET (odds ratio, 1.82; P<0.001). Patients with no such days had 10 times the odds of discontinuing PPIs as those with four days of AET greater than 4.0%. Reduction in symptom burden was greater among the patients who were able to discontinue PPIs than among those who resumed them (RESQ-eD change, −43.7% vs. −5.3%; P=0.04).
The authors concluded that among patients with typical reflux symptoms, inadequate PPI response, and absence of severe esophagitis, acid exposure on reflux monitoring predicted ability to discontinue PPIs without symptom escalation. They noted that symptoms are not as effective a measurement tool, because acid without significant symptoms may still cause longer-term health problems.
“Results from this study support the upfront use of prolonged wireless reflux monitoring to provide a personalized approach to the management of patients with inadequate PPI response,” the authors wrote. “This shift in management could have tremendous implications for patient care as well as health care utilization.” They calculated that upfront wireless reflux monitoring could save between $1,048 to $15,853 per patient compared to empiric PPI therapy, or $35,632 per 100 symptomatic patients with inadequate PPI response.
The authors explained that patients who are found to have little acid on monitoring can be reassured that PPIs are not appropriate for them and be evaluated for alternative causes of their symptoms, whereas those with two or more days of AET require PPI treatment. “Patients with mild elevation in acid exposure may demonstrate varying ability to stop PPI therapy. This group should be counseled that acid exposure is mild with therapeutic focus on lifestyle optimization, particularly weight management, complemented by behavioral or pharmacologic treatment as needed,” the authors said.