More than 42% of patients with negative results from pH monitoring studies continue proton pump inhibitor (PPI) therapy, despite evidence that they do not have gastroesophageal reflux disease (GERD), according to the June issue of Clinical Gastroenterology and Hepatology.
PPI therapy is effective for about 75% of patients with GERD patients. However, if it fails to relieve symptoms, professional guidelines recommend pursuing endoscopy and ambulatory reflux testing to determine if patients have a different disorder that doesn’t respond to acid suppression. These patients should be managed by withdrawal of PPI therapy to see if the condition worsens, and a search for other diagnoses and treatments. However, little is known about whether physicians and patients take this approach.
Andrew J. Gawron et. al investigated the prevalence of continued use of PPIs among 90 patients whose results from endoscopic and Bravo pH or multichannel intraluminal impedance-pH (MII-pH) tests yielded negative results.
They found that 38 of the patients (42.2%) continued taking PPIs despite a negative result from a pH study. Only 17 (18.9%) recalled being instructed to stop taking PPIs; a chart review found that only 15 (16.7%) had documented evidence of being instructed to stop PPI therapy.
“Of those patients that kept taking a PPI, over a third were taking twice daily (or high-dose) therapy,” said Gawron in a video abstract that accompanied the article:
Patients that kept taking the PPIs were more likely than those who stopped to report troublesome symptoms that affected their daily life.
The authors propose that many of the patients might be classified as having functional heartburn, based on the negative pH test results with continued symptoms.
“We think that our study reveals potential opportunities for clinicians to improve counseling after patients have negative [results] from pH testing,” said Gawron, proposing a more systematic approach to patients whose reflux testing yields negative results.
A recent cost-effectiveness analysis showed that early and increased use of pH monitoring could lead to less PPI use without a significant increase in cost to managed health care plans. However, testing alone is not sufficient if practitioners do not adequately communicate results to patients or patients don’t follow recommendations.
The authors add that it is possible that some of the patients might have symptoms from nonacid reflux. However, the prevalence of nonacid reflux has been reported to be ∼18%, leaving a substantial proportion of patients on PPI therapy without reflux disease (acid or nonacid).
Gawron et. al propose prospective studies to better stratify patients who respond poorly to PPIs based on physiological parameters and evaluate strategies to expedite diagnostic testing and improve follow-up analysis.
Read the article online. This article has accompanying CME activities.
Gawron AJ, Rothe J, Fought AJ, et al. Many patients continue using proton pump inhibitors after negative results from tests for reflux disease. Clin Gastroenterol Hepatol 2012;10:620–625.