Management of Reflux Esophagitis: Does the Choice of Proton Pump Inhibitor Matter?

J. Labenz; D. Armstrong; A. Leodolter I. Baldycheva

Disclosures

Int J Clin Pract. 2015;69(7):796-801. 

In This Article

Abstract and Introduction

Abstract

Background: Proton pump inhibitors (PPIs) are the treatment of choice for reflux esophagitis (RE). The effectiveness of PPIs throughout RE management, from healing to maintenance, has not been fully studied.

Aim: To compare esomeprazole with lansoprazole or pantoprazole for RE management using a management model.

Methods: Data from six studies comparing esomeprazole with lansoprazole or pantoprazole for healing (4–8 weeks) or maintenance of healing (6 months) of RE were incorporated into hypothetical management models to determine the proportion of patients in endoscopic remission after sequential healing and maintenance therapy, assuming that patients received the same PPI throughout. The number needed to treat (NNT) to achieve one more patient in remission with esomeprazole vs. other PPIs was estimated. The hypothetical model was validated using results from the EXPO study, which compared esomeprazole with pantoprazole for RE healing and maintenance.

Results: Overall, esomeprazole 40 mg produced higher rates of healing (life-table estimates) than lansoprazole 30 mg (82.4–92.6% vs. 77.5–88.8%; p < 0.01) or pantoprazole 40 mg (95.5% vs. 92.0%; p < 0.001) and higher rates of endoscopic and symptomatic remission at 6 months than lansoprazole (83.0–84.8% vs. 74.0–75.9%; p < 0.001; life-table estimates) or pantoprazole (70.9% vs. 59.6%; p < 0.0001; observed rates). In the hypothetical management model, the NNT for esomeprazole was 9 vs. lansoprazole and 8 vs. pantoprazole. The actual NNT for esomeprazole vs. pantoprazole in the EXPO study was 9 (95% confidence interval: 6; 16).

Conclusions: In this management model, esomeprazole was more effective than either lansoprazole or pantoprazole for maintaining remission after sequential healing and 6 months' maintenance therapy for RE.

Introduction

Gastroesophageal reflux disease (GERD) is a chronic condition[1,2] associated with troublesome symptoms that significantly reduce quality of life.[3,4] Possible complications include reflux esophagitis (RE), which may affect up to 50% of GERD patients.[5] For patients with RE, short-term management goals include prompt resolution of symptoms and healing of erosions.[6] However, following initial healing of RE, few patients remain in endoscopic and symptomatic remission unless provided with maintenance therapy.[7] Therefore, long-term maintenance therapy is necessary for the prevention of recurrent RE and GERD symptoms in a high proportion of patients.

Proton pump inhibitors (PPIs) are the treatment of choice for both healing and maintenance therapy of RE.[8–10] Numerous studies have demonstrated the efficacy of PPIs for initial healing of RE[11–18] and numerous separate studies have demonstrated the efficacy of PPIs for maintaining endoscopic remission.[8,10] The EXPO study,[14,15] which compared esomeprazole with pantoprazole, is one of the few clinical trials to follow patients with RE through the entire course of management, i.e. initial healing of RE and subsequent maintenance of remission of healing. However, comparative data for other PPIs are lacking.

The aim of this analysis was to compare the outcome of RE treatment (i.e. initial healing for 4–8 weeks followed by maintenance for 6 months) with esomeprazole, lansoprazole or pantoprazole, using a hypothetical management model. This hypothetical model was then validated using data from the EXPO study (an 'actual' management model).[14,15]

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