Refractory Reflux Symptoms: A Guide for Discontinuation of PPI Treatment

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A proportion of patients with gastroesophageal reflux symptoms are refractory to PPI therapy. In order to develop a diagnostic approach to identify candidates appropriate for PPI cessation and to examine the clinical utility of prolonged wireless reflux monitoring to predict the ability to discontinue PPIs, a double-blinded, clinical trial performed over 3 years at 2 centers was carried out.

Adults were enrolled with troublesome esophageal symptoms of heartburn, regurgitation, and/or chest pain and inadequate PPI response. Participants underwent prolonged wireless reflux monitoring (off PPIs for greater than 7 days), and a 3-week PPI cessation intervention. Primary outcome was tolerance of PPI cessation (discontinued or resumed PPIs). Symptom burden was quantified using the reflux symptom questionnaire, electronic diary (RESQ-eD).

Of 128 enrolled, 100 participants met inclusion criteria (mean age 48.6 years; 41 men, 34 participants, 34% discontinued PPIs). The strongest predictor of PPI discontinuation was number of days with acid exposure time (AET) greater than 4%. Participants with 0 days of AET greater than 4% had a 10x increased odds of discontinuing PPI than participants with 4 days of AET greater than 4%. Reduction in symptom burden was greater among the discontinued vs. resumed PPI group.

It was concluded among patients with typical reflux symptoms, inadequate PPI response and absence of severe esophagitis, acid exposure on reflux monitoring predicted the ability to discontinue PPIs without symptom escalation. Upfront reflux monitoring of acid suppression can limit unnecessary PPI use and guide personalized management.

Yadlapati, R., Mishia, M., Gayawali, C., et al. “Ambulatory Reflux Monitoring Guides Proton Pump Inhibitor Discontinuation in Patients with Gastroesophageal Reflux Symptoms: A Clinical Trial.” Gastroenterology 2021; Vol. 160, pp. 174-182, January 2021.

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