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Use of Esophageal pH Monitoring to Minimize Proton-Pump Inhibitor Utilization in Patients with Gastroesophageal
George Triadafilopoulos1, Thomas Zikos2, Kirsten Regalia2
1Stanford Esophageal Multidisciplinary Program in Innovative Research Excellence (SEMPIRE), Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 300 Pasteur Drive, M-211, Stanford, CA, 94305, USA. vagt@stanford.edu.
Background:
Due to concerns about long-term PPI use in patients with acid reflux, we aimed at minimizing PPI use, either by avoiding initiating therapy, downscaling to other therapies, or introducing endoscopic or surgical options.
Aims:
To examine the role of esophageal ambulatory pHmetry in minimizing PPI use in patients with heartburn and acid regurgitation.
Methods:
Retrospective cohort analysis of patients with reflux symptoms, who underwent endoscopy, manometry, and ambulatory pHmetry to define the need for PPI. Patients were classified as: (1) never users; (2) partial responders to PPI; (3) users with complete response to PPI. Patients were then managed as: (1) PPI non-users; (2) PPI-initiated, and (3) PPI-continued.
Results:
Of 286 patients with heartburn and regurgitation, 103 (36%) were found to have normal and 183 (64%) abnormal esophageal acid exposure (AET). In the normal AET group, 44/103 had not been treated and were not initiated on PPI. Of the 59 who had previously received PPI, 52 stopped and 7 continued PPI. Hence, PPI were avoided in 96/103 patients (93%). In the abnormal AET group, 61/183 had not been treated and 38 were initiated on PPI and 23 on other therapies. In the 122 patients previously treated with PPI, 24 were not treated with PPI, but with H2RAs, prokinetics, endoscopic, or surgical therapy. Hence, PPI therapy was avoided in 47/183 patients (26%).
Conclusions:
In patients with GER symptoms, esophageal pHmetry may avert PPI use in 50%. In the era of caution regarding PPIs, early testing may provide assurance and justification.
Insights
Esophageal pH monitoring can help reduce proton pump inhibitor (PPI) use in GERD patients. Early pH testing may guide appropriate therapy, averting unnecessary PPI prescriptions.
Area of Science:
- Gastroenterology
- Gastrointestinal Motility Disorders
- Acid Reflux Management
Background:
- Long-term proton pump inhibitor (PPI) use raises concerns for patients with acid reflux.
- Minimizing PPI therapy is a clinical goal, exploring alternatives like other medications or procedures.
Purpose of the Study:
- To evaluate the utility of esophageal ambulatory pH monitoring in reducing PPI use for heartburn and acid regurgitation.
- To determine if pH monitoring can guide de-escalation or avoidance of PPI therapy.
Main Methods:
- Retrospective cohort analysis of 286 patients with reflux symptoms undergoing endoscopy, manometry, and ambulatory pHmetry.
- Patients were classified by prior PPI use and response, and managed by PPI initiation, continuation, or avoidance.
- Esophageal acid exposure (AET) was assessed to guide management decisions.
Main Results:
- 93% of patients with normal esophageal acid exposure (AET) avoided PPIs, with 52/59 stopping prior therapy.
- 26% of patients with abnormal AET avoided PPIs, with 24/122 switched to alternative therapies (H2RAs, prokinetics, endoscopic, or surgical).
- Overall, PPI use was averted in a significant proportion of patients based on pHmetry results.
Conclusions:
- Esophageal pHmetry can help avert PPI use in approximately 50% of patients with gastroesophageal reflux (GER) symptoms.
- In an era of caution regarding PPIs, early pH testing provides justification for management decisions.
- pH monitoring aids in optimizing therapy and potentially reducing long-term PPI exposure.
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