On-demand Versus Continuous Maintenance Treatment of GERD with Proton Pump Inhibitors
A Systematic Review and
Meta-analysis
Gastroesophageal reflux disease (GERD) is a chronic digestive disorder resulting from the reflux of gastric contents into the esophagus that is often accompanied by troublesome symptoms of heartburn, acid regurgitation, or other extra-esophageal symptoms such as chest pain, chronic cough, hoarseness or globus.
Effective treatment
strategy for GERD patients
· Currently, acid suppressive therapy with proton pump inhibitors (PPIs) has proved to be the most effective treatment strategy for GERD patients and is recommended as a first-line treatment. PPIs have shown superiority over histamine H2-receptor antagonists for controlling symptoms as well as for healing erosions.
· Although symptomatic relief and acute healing of esophageal lesions can be achieved by short-term PPI treatments, up to 75% of patients with Non-erosive reflux disease (NERD) and up to 90% of patients with Erosive reflux disease (ERD) experience relapse within 6 months to 1 year after termination of initial treatments. Long-term continuous maintenance treatment with PPIs is required for the majority of patients with GERD to adequately control symptoms and to heal mucosal lesions.
Advantage &
Disadvantage of On-demand and Continuous Maintenance Treatment
Recent studies suggest
that long-term PPI treatment can increase the risk of Clostridium difficile or
other enteric infection, kidney disease, bone fractures, or micronutrient
deficiency.
Therefore, maintenance therapy such as “on-demand” PPI
therapy or “intermittent” PPI therapy have been used in clinical practice and
their effectiveness has also been studied.
·
The
severity of esophagitis significantly influenced the effect of the 2
maintenance therapies. In particular, continuous maintenance treatment seems to
be more effective in patients with severe ERD.
·
On-demand
PPI therapy showed similar efficacies to continuous therapy in the outcome of
treatment failure, symptom relief, and patient satisfaction in GERD patients,
especially in NERD and mild ERD patients, and Asian patients.
· However, on-demand therapy has the advantage of reducing the amount of PPI usage by half compared to the continuous therapy. Therefore, the on-demand PPI therapy is recommended as an effective maintenance treatment modality in GERD patients unaccompanied by severe esophagitis.
On-demand PPI therapy means that patients take a daily
dose of a PPI when symptoms recur and stop medication when symptoms resolve.
Intermittent PPI
therapy is when
patients take a regular daily dose of a PPI upon symptom relapse and continue for
a pre-specified duration, which is typically 1 or 2 weeks regardless of symptom
response.
Erosive reflux disease
(ERD) is defined as
mucosal defect by endoscopy and occurs in approximately 25% of patients with
GERD symptoms.
Non-erosive reflux
disease (NERD) is
present in approximately 70% of patients and is characterized by the presence
of typical GERD symptoms associated with pathological acid reflux but the
absence of demonstrable esophageal mucosal injury on endoscopy.
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Background/Aims
Long-term maintenance treatment of gastroesophageal reflux disease (GERD) is
commonly used to prevent relapse of reflux symptoms; however, due to concerns
about safety of long-term proton pump inhibitors (PPI) use, on-demand therapy
is recommended as a longterm treatment modality. We compared the efficacy of
on-demand and continuous PPI therapy for maintenance treatment of patients with
GERD using meta-analysis.
Methods
Core electronic databases were searched for randomized controlled trials
comparing on-demand and continuous therapy in GERD patients. The primary
outcome was treatment failure of maintenance therapy, and the secondary
outcomes included symptomatic relief, patient satisfaction, and amount of PPI
use.
Results
Overall, 11 studies were selected in the systematic review and meta-analysis.
Compared with continuous PPI therapy, on-demand therapy showed similar outcomes
for treatment failure (risk ratio, 1.26; 95% confidence interval, particularly
in the non-erosive esophageal reflux disease and mild erosive reflux disease
group. In studies including severe esophagitis patients, continuous PPI
maintenance treatment was more effective. Severity of esophagitis was
associated with higher efficacies of continuous maintenance therapy. The amount
of daily PPI use was about half in the on-demand group compared to the
continuous group.
Conclusions
On-demand PPI therapy shows comparable efficacy to the continuous maintenance
treatment in the non-erosive esophageal reflux disease and mild erosive reflux
disease group, and can remarkably reduce the amount of PPI use. Therefore,
on-demand therapy may be preferentially recommended in the maintenance
treatment of GERD unaccompanied by severe esophagitis.
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