Short‐term treatment with proton pump inhibitors, H2‐receptor antagonists and prokinetics for gastro‐oesophageal reflux disease‐like symptoms and endoscopy negative reflux disease
Abstract
Background
Approximately 25% of adults regularly experience heartburn, a symptom of gastro‐oesophageal reflux disease (GORD). Most patients are treated empirically (without specific diagnostic evaluation e.g. endoscopy. Among patients who have an upper endoscopy, findings range from a normal appearance, mild erythema to severe oesophagitis with stricture formation. Patients without visible damage to the oesophagus have endoscopy negative reflux disease (ENRD). The pathogenesis of ENRD, and its response to treatment may differ from GORD with oesophagitis.
Objectives
Summarise, quantify and compare the efficacy of short‐term use of proton pump inhibitors (PPI), H2‐receptor antagonists (H2RA) and prokinetics in adults with GORD, treated empirically and in those with endoscopy negative reflux disease (ENRD).
Search methods
We searched MEDLINE (January 1966 to November 2008), EMBASE (January 1988 to November 2008), and EBMR in November 2008.
Selection criteria
Randomised controlled trials reporting symptomatic outcome after short‐term treatment for GORD using proton pump inhibitors, H2‐receptor antagonists or prokinetic agents. Participants had to be either from an empirical treatment group (no endoscopy used in treatment allocation) or from an endoscopy negative reflux disease group (no signs of erosive oesophagitis).
Data collection and analysis
Two authors independently assessed trial quality and extracted data.
Main results
Thirty‐two trials (9738 participants) were included: fifteen in the empirical treatment group, thirteen in the ENRD group and four in both. In empirical treatment of GORD the relative risk (RR) for heartburn remission (the primary efficacy variable) in placebo‐controlled trials for PPI was 0.37 (two trials, 95% confidence interval (CI) 0.32 to 0.44), for H2RAs 0.77 (two trials, 95% CI 0.60 to 0.99) and for prokinetics 0.86 (one trial, 95% CI 0.73 to 1.01). In a direct comparison PPIs were more effective than H2RAs (seven trials, RR 0.66, 95% CI 0.60 to 0.73) and prokinetics (two trials, RR 0.53, 95% CI 0.32 to 0.87).
In treatment of ENRD, the RR for heartburn remission for PPI versus placebo was 0.73 (eight trials, 95% CI 0.67 to 0.78) and for H2RA versus placebo was 0.84 (two trials, 95% CI 0.74 to 0.95). The RR for PPI versus H2RA was 0.78 (three trials, 95% CI 0.62 to 0.97) and for PPI versus prokinetic 0.72 (one trial, 95% CI 0.56 to 0.92).
Authors' conclusions
PPIs are more effective than H2RAs in relieving heartburn in patients with GORD who are treated empirically and in those with ENRD, although the magnitude of benefit is greater for those treated empirically.
Plain language summary
Short‐term treatment with medications for heartburn symptoms.
Patients with only mild or intermittent heartburn may have adequate relief with lifestyle modifications and antacids, although other options are available. The two most commonly used drugs for treatment of heartburn are H2‐receptor antagonists (H2RAs) and proton pump inhibitors (PPIs). These drugs act by suppressing the discharge of acid from the stomach. This review found that in the short term PPIs relieve heartburn better than H2RAs in patients who are treated without specific diagnostic testing and, although the difference is smaller, in patients with GORD who have a normal upper endoscopy too. In summary, proton pump inhibitor drugs appear to be more effective than H2‐receptor antagonists for relieving heartburn, the cardinal feature of "gastro‐oesophageal reflux disease" (GORD).
