Gastroenterology

Gastroenterology

Volume 122, Issue 3, March 2002, Pages 625-632
Gastroenterology

Clinical Research
Long-term effect of H2RA therapy on nocturnal gastric acid breakthrough,☆☆

https://doi.org/10.1053/gast.2002.31876Get rights and content

Abstract

Background & Aims: Adding histamine 2 receptor antagonists (H2RAs) to proton pump inhibitor (PPI) therapy is a common practice to block nocturnal acid breakthrough (NAB). Controversy exists over its efficacy because of H2RA intolerance. No prospective study has addressed this issue. Methods: Twenty-three healthy volunteers and 20 gastroesophageal reflux disease (GERD) patients were studied. Ambulatory pH monitoring was performed with one electrode in the gastric fundus and the other 5 cm above the lower esophageal sphincter. Baseline pH testing was performed and repeated after 2 weeks on PPI twice daily before meals (omeprazole 20 mg). All subjects then received 28 days of PPI plus H2RA Qhs (ranitidine 300 mg) with repeat pH testing on days 1, 7, and 28. Results: Eighteen controls and 16 GERD patients completed all 5 studies. Compared with baseline, all 4 medication regimens decreased supine % time pH < 4 (P = 0.001). The administration of PPI + 1 day of H2RA was the only therapy that significantly decreased % time gastric pH < 4 for the supine period compared with PPI twice daily alone (P < 0.001). There was no difference in % time supine gastric pH < 4 between 2 weeks of PPI twice daily alone and either 1 week or 1 month of PPI + bedtime H2RA. Conclusions: The combination of H2RA and PPI therapy reduced NAB only with the introduction of therapy. Because of H2RA tolerance, there is no difference in acid suppression between PPI twice daily and PPI twice daily + H2RA after 1 week of combination therapy.

GASTROENTEROLOGY 2002;122:625-632

Section snippets

Patients

We prospectively evaluated 23 healthy volunteers and 20 patients with GERD. Patients were recruited to the Center for Swallowing and Esophageal Disorders through an advertisement campaign. All volunteers answered a questionnaire to determine medical histories and demographics. Healthy volunteers complained of no symptoms suggestive of GERD and had normal esophageal acid exposure by 24-hour ambulatory gastroesophageal pH level monitoring. Patients who described symptoms of GERD had either

Demographics

Twenty-three normal volunteers (11 men, 12 women), mean age 32 years (range, 21–51 years), and 20 patients with GERD (14 men, 6 women), mean age 41 years (range, 21–71 years), were enrolled in the study protocol. Three volunteers were dropped because of medication noncompliance. Two volunteers and 4 GERD patients were unable to complete all 5 pH studies successfully. Therefore, complete data was analyzed on 34 participants, 18 normal volunteers and 16 GERD patients. Four of 18 normals had

Discussion

Our findings support earlier conclusions that the addition of an H2RA to twice-daily PPI therapy significantly reduces the appearance of nocturnal gastric acid; however, this phenomenon is temporary for most people. After only 1 week of continuous bedtime H2RA administration, there is a significant reduction in the acid inhibitory effect yielded by ranitidine at 1 day. After 1 month of uninterrupted H2RA therapy, gastric acidity has returned to pre-H2RA levels, and there is no meaningful

References (35)

  • CBHW Lamers et al.

    Omeprazole in Zollinger-Ellison syndrome. Effects of a single dose and of long-term treatment in patients resistant to histamine H2-receptor antagonists

    N Engl J Med

    (1984)
  • P Ducrotte et al.

    Comparison of omeprazole and famotidine on esophageal pH in patients with moderate to severe esophagitis: a cross over study

    Am J Gastroenterol

    (1994)
  • CM Bate et al.

    Comparison of omeprazole and cimetidine in reflux esophagitis: symptomatic, endoscopic, and histologic evaluations

    Gut

    (1990)
  • Cooperative study group

    Double blind comparative study of omeprazole and ranitidine in patients with duodenal or gastric ulcer: a multicentre trial

    Gut

    (1990)
  • G Brunner et al.

    Therapy with omeprazole in patients with peptic ulcerations resistant to extended high-dose ranitidine treatment

    Digestion

    (1988)
  • B Kuo et al.

    Optimal dosing of omeprazole 40 mg daily: effects on gastric and esophageal pH and serum gastrin in healthy controls

    Am J Gastroenterol

    (1996)
  • LP Leite et al.

    Persistent acid secretion during omeprazole therapy: a study of gastric acid profiles in patients demonstrating failure of omeprazole therapy

    Am J Gastroenterol

    (1996)
  • Cited by (0)

    Address reprint requests to: Joel E. Richter, M.D., Department of Gastroenterology, A30, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, Ohio 44195. e-mail: [email protected]; fax: (216) 444-9416.

    ☆☆

    Supported by an educational grant from Astra-Zeneca and the Borra Family Endowment for Esophageal and Swallowing Disorders.

    View full text