Many Patients Without Acid Reflux Stay on PPIs


Many patients continue to use proton pump inhibitors after pH testing shows that they do not have acid reflux, Dr. Andrew J. Gawron and his colleagues reported in the June issue of Clinical Gastroenterology and Hepatology.

In this cross-sectional, observational study, investigators conducted phone interviews with 90 patients who had received negative results on pH testing months to years earlier (mean of 25.0 months). Of these 90 people, fully 42% (38 patients), were still taking PPIs.

Most of these patients reported having persistent, troublesome symptoms every day, and "a significant proportion" had scores on the GerdQ that would be considered diagnostic of gastroesophageal reflux disease (GERD), said Dr. Gawron of the division of gastroenterology and hepatology and the Institute for Healthcare Studies at Northwestern University, Chicago, and his associates (Clin. Gastro. Hepatol. 2012 Feb. 23 [doi:10.1016/j.cgh.2012.02.012]).

Only 17 patients (19%) remembered being instructed to discontinue their PPI after receiving their test results, and only 15 had documentation of this instruction in their charts. Patients who continued taking PPIs were slightly older than those who stopped their PPIs after negative pH testing (50.3 vs. 46.8 years, respectively).

The study findings suggest that clinicians should improve their patient counseling methods and be more systematic in their approach to patients whose reflux testing yields negative results. The study’s conclusions also "highlight the need for improved strategies to identify alternative diagnoses and treatments for patients whose symptoms are inadequately relieved by PPIs," the investigators said.

Overuse of PPIs has been demonstrated in numerous studies. In the current study, Dr. Gawron and his colleagues reviewed the records of 90 patients who had been referred for ambulatory pH testing in 2006-2010, using endoscopy plus either 48-hour Bravo pH monitoring (66 subjects) or multichannel intraluminal impedance-pH testing (24 subjects). All had received negative results indicating that they did not have GERD.

These patients were later contacted by phone and completed the GerdQ, a questionnaire that quantifies GERD symptoms and their impact on daily life. The GerdQ has shown similar accuracy to a gastroenterologist’s assessment in diagnosing GERD, the researchers noted.

The study subjects also completed a telephone questionnaire regarding their general health status.

In all, 38 patients said they were currently using PPIs, and 13 were taking their PPI twice a day, despite their negative results on pH testing. Most used esomeprazole (13 subjects) or omeprazole (11 subjects).

A total of 56% of the subjects who continued to take PPIs had positive scores on the GerdQ, which would indicate that they did have GERD. In contrast, only 21% of the subjects who discontinued PPIs had positive GerdQ scores.

Mean age, sex, race, body mass index, marital status, income, and education level were similar between patients who continued taking PPIs and those who did not. Also, there were no differences between the two groups in outpatient visits to either primary care or gastroenterology physicians, use of medication for depression or anxiety, or general health status.

The only clinical or demographic factor that appeared to differ between the two groups was alcohol intake: 90% of patients who were not taking a PPI reported alcohol use, while only 63% of those who were taking a PPI did so. This suggests that symptoms were bothersome enough for patients who continued taking PPIs that they reduced their alcohol consumption.

Although PPIs are often prescribed for gastroprotection in patients who are taking concomitant aspirin or NSAID therapy, this did not account for the continued use of PPIs in this study population. Only 12 patients reported taking aspirin and only 8 reported taking NSAIDs.

This study was supported by the U.S. Public Health Service and the Agency for Healthcare Research and Quality. Dr. Gawron reported no financial conflicts of interest. His coauthors reported ties to AstraZeneca, Eisai, EndoGastric Solutions, Ironwood, Torax, Reckitt Benckiser, Given, Sandhill, Shire, and Crospon.

Recommended Reading

Duodenal GIST Responds to Surgery, Imatinib
MDedge Family Medicine
Fecal Transplant Tackles C. diff; Linezolid Good for MRSA Pneumonia
MDedge Family Medicine
Variceal Rebleeding Twice as Likely If Beta-Blockers Fail
MDedge Family Medicine
Intensive Follow-Up Reduces Mortality From Hepatocellular Cancer
MDedge Family Medicine
Data Supporting Probiotics' Benefit Found Weak but Favorable
MDedge Family Medicine
Meta-Analysis Links Acid Suppression to C. difficile Risk
MDedge Family Medicine
Norovirus Outbreak Traced to Reusable Grocery Bag
MDedge Family Medicine
Antibiotics/Probiotics Helpful in Irritable Bowel Syndrome
MDedge Family Medicine
Fatty Acids in Fish May Lower Liver Cancer Risk
MDedge Family Medicine
"Hemorrhoids" turn out to be cancer … and more
MDedge Family Medicine