Maintenance Proton Pump Inhibitor Research Articles

Short-term cost effectiveness and long-term cost analysis comparing laparoscopic Nissen fundoplication with proton-pump inhibitor maintenance for gastro-oesophageal reflux disease

This study examined the short-term cost-effectiveness and long-term cost of laparoscopic Nissen fundoplication (LNF) versus maintenance proton-pump inhibitor (PPI) medication for severe gastro-oesophageal reflux disease (GORD) based on a randomized clinical trial. Costs and outcomes for 12 months were obtained from the first 100 patients in the trial. Detailed costing was performed using resource use data from hospital records and general practitioners' notes. Short-term incremental cost-effectiveness ratios, calculated as the cost difference divided by the effectiveness difference between LNF and PPI therapy, were analysed using net benefit and bootstrap approaches. Long-term cost was examined using sensitivity analyses incorporating published data from other large series. The incremental cost of LNF compared with PPI therapy per additional patient returned to a physiologically normal acid score (less than 13.9) at 3 months was pound5515 (95 per cent confidence interval (c.i.) pound3655 to pound13 400) and the incremental cost per point improvement in combined Gastro-Intestinal and Psychological Well-being score at 12 months was pound293 (90 per cent c.i. pound149 to pound5250). On average, LNF cost pound2247 (95 per cent c.i. pound2020 to pound2473) more than PPI therapy in year 1 and broke even in year 8. Break-even was highly sensitive to hospital unit costs but less sensitive to PPI ingestion rate after LNF, LNF reoperation rate, PPI relapse rate, future PPI price, PPI dose escalation and discount rate. From a National Health Service perspective, LNF may be cost-saving after 8 years compared with maintenance PPI therapy for the treatment of GORD.

Safety and Efficacy of Enteryx for Treatment of GERD in Patients with GERD and Asthma: A Pilot Study

Enteryx™, a non-resorbing biocompatible polymer has been shown to facilitate the reduction or discontinuation of proton pump inhibitor (PPI) therapy in patients with chronic gastroesophageal reflux disease (GERD). There appears to be a strong association between GERD and asthma. Up to 45% of asthmatic patients experience at least one episode of symptomatic GERD per week vs. only 10% of non-asthmatic controls. In carefully selected patients with GERD and asthma, medical and surgical treatments have been shown to control GERD and in some cases improve asthma symptoms. The primary aim of this study was to evaluate the safety and efficacy of Enteryx™ in patients with GERD and asthma. Methods: 52 patients with GERD and asthma were identified in our Asthma Clinic. All patients were taking maintenance PPI therapy. Ten agreed to participate in the study. Bravo™ pH monitoring was performed in all ten. Eight had positive pH testing, defined as a DeMeester Score of > 14.7. Six agreed to participate, one was excluded at the principal investigator's (PI's) discretion. All procedures were performed by the PI. Enteryx™ was injected into the muscular layer of the esophagus under fluoroscopic guidance at or 1 cm below the z-line. 1cc minimum aliquots were placed with each injection. An average of 5.88 cc (range 3.7-7.2) of Enteryx™ was injected during each session. All patients received sedation with propofol administered by an anesthesiologist or nurse anesthetist. There were no serious adverse events associated with the procedure or the sedation. Mean procedure time was 38 minutes. Standardized health-related quality of life questionnaires (HRQL) for GERD and for asthma along with medication use were measured before implantation and at 1, 2, and 4 weeks after the procedure. Results: At week 4 a statistically significant (p < 0.05) improvement in HRQL for both GERD and asthma was demonstrated following the Enteryx™ procedures. A trend toward linear relationship between GERD and asthma HRQL was also noted. Conclusion: Based on the interim analysis of our data the Enteryx™ procedure appears to be safe and effective in carefully selected patients with GERD and asthma. A statistically significant improvement in both GERD and asthma HRQL scores was demonstrated. Moreover, a trend toward a direct relationship between the improvement in GERD HRQL and asthma HRQL scores was seen. Enrollment continues, we await the 6 and 12-month follow-up data to confirm our initial results. Enteryx™, a non-resorbing biocompatible polymer has been shown to facilitate the reduction or discontinuation of proton pump inhibitor (PPI) therapy in patients with chronic gastroesophageal reflux disease (GERD). There appears to be a strong association between GERD and asthma. Up to 45% of asthmatic patients experience at least one episode of symptomatic GERD per week vs. only 10% of non-asthmatic controls. In carefully selected patients with GERD and asthma, medical and surgical treatments have been shown to control GERD and in some cases improve asthma symptoms. The primary aim of this study was to evaluate the safety and efficacy of Enteryx™ in patients with GERD and asthma. Methods: 52 patients with GERD and asthma were identified in our Asthma Clinic. All patients were taking maintenance PPI therapy. Ten agreed to participate in the study. Bravo™ pH monitoring was performed in all ten. Eight had positive pH testing, defined as a DeMeester Score of > 14.7. Six agreed to participate, one was excluded at the principal investigator's (PI's) discretion. All procedures were performed by the PI. Enteryx™ was injected into the muscular layer of the esophagus under fluoroscopic guidance at or 1 cm below the z-line. 1cc minimum aliquots were placed with each injection. An average of 5.88 cc (range 3.7-7.2) of Enteryx™ was injected during each session. All patients received sedation with propofol administered by an anesthesiologist or nurse anesthetist. There were no serious adverse events associated with the procedure or the sedation. Mean procedure time was 38 minutes. Standardized health-related quality of life questionnaires (HRQL) for GERD and for asthma along with medication use were measured before implantation and at 1, 2, and 4 weeks after the procedure. Results: At week 4 a statistically significant (p < 0.05) improvement in HRQL for both GERD and asthma was demonstrated following the Enteryx™ procedures. A trend toward linear relationship between GERD and asthma HRQL was also noted. Conclusion: Based on the interim analysis of our data the Enteryx™ procedure appears to be safe and effective in carefully selected patients with GERD and asthma. A statistically significant improvement in both GERD and asthma HRQL scores was demonstrated. Moreover, a trend toward a direct relationship between the improvement in GERD HRQL and asthma HRQL scores was seen. Enrollment continues, we await the 6 and 12-month follow-up data to confirm our initial results.

Cost minimization of on-demand maintenance therapy with proton pump inhibitors in nonerosive gastroesophageal reflux disease

On-demand proton pump inhibitor maintenance therapy is one of the suggested strategies for patients with nonerosive gastroesophageal reflux disease who achieve symptom remission after 4 weeks of continuous treatment. This review evaluates the difference in cost and quality of life of six on-demand proton pump inhibitor maintenance strategies in patients with nonerosive gastroesophageal reflux disease. This was performed by decision analysis and Markov modeling of costs (from the perspective of the healthcare service and society) and utility up to 12 months. Median utility scores associated with each proton pump inhibitor ranged from 0.731 to 0.745 quality-adjusted life years and were not statistically different. Annual expected cost, however, was statistically different among the different drugs and the following cost-minimization ranking was obtained for median costs to the healthcare service and society, respectively: rabeprazole (€181, €295), pantoprazole (€223, €341), lansoprazole (€249, €370), omeprazole 10 mg (€297, €412), esomeprazole (€295, €419) and omeprazole 20 mg (€405, €528). Unit cost of proton pump inhibitors was the major determinant of cost to the healthcare service, while the number of productivity days lost due to symptoms was the major determinant of cost to society. In Italy, on-demand use of rabeprazole for maintenance therapy of nonerosive gastroesophageal reflux disease incurs the least cost in comparison with the other proton pump inhibitors evaluated.

Maintenance Therapy in Gastro-oesophageal Reflux Disease

Gastro-oesophageal reflux disease (GORD) is a chronic condition. Symptom control and the maintenance of healing of erosive oesophagitis, if present, are important topics. In patients responding to a proton pump inhibitor (PPI) and showing no treatment symptoms it is appropriate to consider long-term treatment strategies, whether continuous, intermittent or on demand. Maintenance PPI therapy is well tolerated for up to 10 years of continuous use. Furthermore, tachyphylaxis does not occur during long-term maintenance PPI therapy. Previous concerns about risks of long-term PPI therapy in Heliobacter pylori-negative or H. pylori-positive patients have not materialized, while no cases of intestinal metaplasia with dysplasia or adenocarcinoma were found. The choice between medical and surgical therapy should depend upon informed patient preference. The optimal candidate for antireflux surgery is a young patient, with typical GORD symptoms, with erosive oesophagitis, with previous complete symptom resolution on acid-suppression therapy and unable to undergo continuous therapy, or alternatively in patients with regurgitation predominating over heartburn as long as the surgical procedures are conducted by an expert surgical team. Endoscopic therapy for erosive GORD should currently be regarded as experimental. The endoscopic procedures are safe, although they remain untested in patients with severe erosive oesophagitis and/or significant hiatal hernia.

Management strategies for gastroesophageal reflux disease.

In the treatment of gastroesophageal reflux disease (GERD), the most effective treatment option is the use of proton pump inhibitor (PPI), which minimizes the effect of gastric acid on the distal esophagus. Both the step-up and step-down treatment strategies have advantages and disadvantages. Most physicians would like to choose the step-down therapy rather than the step-up therapy. The 'No-step' PPI therapy (i.e. continuous PPI therapy) is another relevant option. After an initial remission, long-term PPI therapy is an appropriate form of maintenance therapy in many patients. As a treatment plan for non-erosive reflux disease, a standard dose of PPI for 4-8 weeks followed by either the step-down strategy or the on-demand treatment strategy is acceptable. When treating erosive esophagitis, PPI is better than H(2) receptor blockers in healing mucosal breaks and relieving symptoms. Long-term maintenance PPI therapy is reported to be very effective in maintaining the remission of reflux esophagitis for up to 5 years. On-demand PPI is also another good option for a maintenance therapy in erosive esophagitis. In Barrett's esophagus, symptoms seem to be well-controlled with PPIs. Unfortunately, however, PPIs have no effect on the shortening of Barrett's esophagus or in preventing the progression to dysplasia and adenocarcinoma. In summary, after reviewing existing guidelines a rather simple guideline on the management of GERD is suggested - PPI should be given for 4-8 weeks followed by either on-demand or maintenance PPI therapy according to the clinical severity.

Helicobacter pylori and nonmalignant diseases.

This paper reviews the new literature from the past year on the association between colonization with Helicobacter pylori and non-malignant disease of the upper gastrointestinal tract. This issue has, in the past year, remained a topic of wide research interest yielding many important new data. These data show that H. pylori eradication is the most effective therapy for peptic ulcer disease, but that a considerable proportion of ulcer patients remain to have dyspeptic symptoms. The discussion on the interaction between H. pylori and NSAID use in the etiology of ulcer disease has not yet been settled. Several studies, both from Asia and Europe, now reported that H. pylori eradication has a minimal effect on the primary prevention of ulcer disease in NSAID users, but eradication appears of relevance for the secondary prevention of ulcer disease in addition to proton pump inhibitor maintenance therapy. Various studies brought further support for the hypothesis that H. pylori eradication is of some benefit for patients with non-ulcer dyspepsia, although the effects are limited. The prevalence of H. pylori is lower among GERD patients than among controls, but H. pylori eradication has not been consistently shown to increase the risk for the newly development of GERD in an individual subject undergoing H. pylori eradication. The discussion on H. pylori and GERD should not preclude us from treating H. pylori-infected patients for accepted clinical indications. In patients using proton pump inhibitors for GERD, H. pylori eradication leads to a resolution of their corpus-predominant pangastritis, without impairing the efficacy of PPI therapy.

Recurrent duodenal ulcer haemorrhage: a pharmacoeconomic comparison of various management strategies

Background: Duodenal ulcer (DU) bleeding has a 7 – 13% mortality rate and bleeding often recurs. Prevention of recurrence is, therefore, an important goal. Eradication of Helicobacter pylori or maintenance treatment with a proton pump inhibitor (PPI) may reduce recurrent DU bleeding. Economic comparison of these options is sparse.Methods: After the control of index bleeding with endotherapy and drugs, three strategies were evaluated: empirical treatment for possible H. pylori infection followed by a PPI for 2 months; test for H. pylori, eradication if positive, maintenance PPI if negative; maintenance PPI alone. Probability and direct cost data were obtained from a Medline search and Indian hospitals, respectively. Cost-minimisation, cost-utility, one- and two-way sensitivity analyses and threshold values were evaluated.Results: Treatment of H. pylori, particularly empirical, was the preferred strategy and dominated maintenance treatment with PPI. The test-and-treat strategy was better than the empirical treatment strategy only when the probabilities of H. pylori eradication, ulcer healing following eradication and of frequency of H. pylori infection in bleeding DU were less than 58, 73 and 58%, respectively.Conclusions: Eradication of H. pylori is preferred in preventing recurrent bleeding from DU.

Maintenance proton pump inhibitor (PPI) therapy decreases the incidence of esophageal cancer (CA) and high grade dysplasia (HGD) in Barrett’s and chronic heartburn

Purpose: Although maintenance PPI's are empirically advocated in Barrett's esophagus (BE), there is only one study, from this institution, showing a trend in reduction of CA and HGD after 5–11 yrs of maintenance PPI therapy. The aim of this study is to examine whether this trend has been sustained after 6–13 yrs.

Laparoscopic nissen fundoplication versus proton pump inhibitor maintenance for severe gastro-oesophageal reflux disease: Trial based analysis of long-term cost and cost-effectiveness

Laparoscopic nissen fundoplication versus proton pump inhibitor maintenance for severe gastro-oesophageal reflux disease: Trial based analysis of long-term cost and cost-effectiveness

The effect of over the counter ranitidine (75 mg) on nighttime heartburn in patients with erosive esophagitis on daily proton pump inhibitor maintenance therapy

The effect of over the counter ranitidine (75 mg) on nighttime heartburn in patients with erosive esophagitis on daily proton pump inhibitor maintenance therapy

Maintenance oral pantoprazole therapy is effective for patients with Zollinger-Ellison syndrome and idiopathic hypersecretion

Maintenance proton pump inhibitor (PPI) therapy is effective for gastric acid hypersecretory states, although data with pantoprazole are limited. The aim of this study was to evaluate the safety and efficacy of long term p.o. pantoprazole in individuals with hypersecretion. All subjects had Zollinger-Ellison syndrome or idiopathic hypersecretion. Baseline acid output was measured in the presence of prior maintenance antisecretory therapy before pantoprazole exposure. The starting dose was 40 mg b.i.d. in most cases, and the dose was adjusted to document control within the first 2 wk of therapy. The maximal allowable dose was 240 mg daily. Acid output was measured on day 28 and then quarterly from month 3. The primary efficacy endpoint was documented control of acid secretion at 6 months, i.e., acid output in the last 1 h before the next dose of therapy of <10 mEq/h (<5 mEq/h in subjects with prior acid-reducing surgery). A total of 26 subjects had Zollinger-Ellison syndrome (six with multiple endocrine neoplasia syndrome type 1) and nine had idiopathic hypersecretion. Pre-enrollment therapy included omeprazole in 27 subjects and lansoprazole in eight, and 82.4% of subjects were controlled on their prior regimens. With upward dose titration, acid output was controlled in all subjects by day 10 and in all but two (6%) at the 6-month time point. Median acid secretion on therapy at 6 months was <2 mEq/h (mean 2.2 mEq/h; range 0-10.5 mEq/h) at a dose of 40 mg b.i.d. for 24 subjects, 80 mg b.i.d. for seven subjects, and 120 mg b.i.d. for two subjects. During the course of the study, five subjects required doses of 240 mg daily. Pantoprazole was generally well tolerated. No cases of anterior optic ischemic neuropathy occurred. Five subjects died during follow-up, all because of events unrelated to the study drug. Maintenance p.o. pantoprazole therapy at a dose of 80-240 mg/day in divided doses was both effective and generally well tolerated for patients with Zollinger-Ellison syndrome and idiopathic hypersecretion.

Maintenance oral pantoprazole therapy is effective for patients with Zollinger-Ellison syndrome and idiopathic hypersecretion

Objective Maintenance proton pump inhibitor (PPI) therapy is effective for gastric acid hypersecretory states, although data with pantoprazole are limited. The aim of this study was to evaluate the safety and efficacy of long term p.o. pantoprazole in individuals with hypersecretion. Methods All subjects had Zollinger-Ellison syndrome or idiopathic hypersecretion. Baseline acid output was measured in the presence of prior maintenance antisecretory therapy before pantoprazole exposure. The starting dose was 40 mg b.i.d. in most cases, and the dose was adjusted to document control within the first 2 wk of therapy. The maximal allowable dose was 240 mg daily. Acid output was measured on day 28 and then quarterly from month 3. The primary efficacy endpoint was documented control of acid secretion at 6 months, i.e., acid output in the last 1 h before the next dose of therapy of <10 mEq/h (<5 mEq/h in subjects with prior acid-reducing surgery). Results A total of 26 subjects had Zollinger-Ellison syndrome (six with multiple endocrine neoplasia syndrome type 1) and nine had idiopathic hypersecretion. Pre-enrollment therapy included omeprazole in 27 subjects and lansoprazole in eight, and 82.4% of subjects were controlled on their prior regimens. With upward dose titration, acid output was controlled in all subjects by day 10 and in all but two (6%) at the 6-month time point. Median acid secretion on therapy at 6 months was <2 mEq/h (mean 2.2 mEq/h; range 0–10.5 mEq/h) at a dose of 40 mg b.i.d. for 24 subjects, 80 mg b.i.d. for seven subjects, and 120 mg b.i.d. for two subjects. During the course of the study, five subjects required doses of 240 mg daily. Pantoprazole was generally well tolerated. No cases of anterior optic ischemic neuropathy occurred. Five subjects died during follow-up, all because of events unrelated to the study drug. Conclusions Maintenance p.o. pantoprazole therapy at a dose of 80–240 mg/day in divided doses was both effective and generally well tolerated for patients with Zollinger-Ellison syndrome and idiopathic hypersecretion.

Recurrent duodenal ulcer haemorrhage: a pharmacoeconomic comparison of various management strategies

Background: Duodenal ulcer (DU) bleeding has a 7 – 13% mortality rate and bleeding often recurs. Prevention of recurrence is, therefore, an important goal. Eradication of Helicobacter pylori or maintenance treatment with a proton pump inhibitor (PPI) may reduce recurrent DU bleeding. Economic comparison of these options is sparse.Methods: After the control of index bleeding with endotherapy and drugs, three strategies were evaluated: empirical treatment for possible H. pylori infection followed by a PPI for 2 months; test for H. pylori, eradication if positive, maintenance PPI if negative; maintenance PPI alone. Probability and direct cost data were obtained from a Medline search and Indian hospitals, respectively. Cost-minimisation, cost-utility, one- and two-way sensitivity analyses and threshold values were evaluated.Results: Treatment of H. pylori, particularly empirical, was the preferred strategy and dominated maintenance treatment with PPI. The test-and-treat strategy was better than the empirical treatment strategy only when the probabilities of H. pylori eradication, ulcer healing following eradication and of frequency of H. pylori infection in bleeding DU were less than 58, 73 and 58%, respectively.Conclusions: Eradication of H. pylori is preferred in preventing recurrent bleeding from DU.

The cost-effectiveness of competing strategies for the prevention of recurrent peptic ulcer hemorrhage

OBJECTIVE: Several strategies exist for the prevention of recurrent ulcer-related hemorrhage, yet the cost-effectiveness has not been evaluated and remains uncertain. The aim of this study was to compare the cost-effectiveness of competing management strategies considering both nonsteroidal anti-inflammatory drugs status and the accuracy of Helicobacter pylori ( H. pylori) testing. METHODS: Decision analysis was used to compare the cost-per-recurrent hemorrhage prevented for 11 strategies over 1 yr. Clinical and costs estimates were derived from a systematic review of the medical literature and the Medicare Fee Schedule and Drug Topics Redbook. Sensitivity analyses were performed for important variables. RESULTS: The test/retest eradication strategy with maintenance proton pump inhibitor therapy for H. pylori-negative patients was most effective (prevention of recurrence in 96.0%). The test/retest eradication strategy with maintenance histamine-2 receptor antagonist therapy for H. pylori-negative patients was least costly ($1070). The test/retest strategies were dominant with average cost-effectiveness ratios of $1118–1310/recurrent hemorrhage prevented with maintenance antisecretory therapy. The average cost-effectiveness ratios for “selective” H. pylori eradication strategies with maintenance antisecretory therapy were $1263–1673. The model was robust to varying estimates over prespecified ranges. CONCLUSIONS: Test/retest strategies for H. pylori are cost-effective for the prevention of recurrent ulcer-related hemorrhage because they maximize H. pylori detection and eradication, resulting in fewer recurrent hemorrhages and fewer patients requiring antisecretory therapy.

Lansoprazole for maintenance of remission of erosive oesophagitis.

Gastro-oesophageal reflux disease, which is experienced daily by a significant proportion of individuals, may result in serious sequelae such as erosive oesophagitis. Short-term treatment with acid antisecretory therapy (a proton pump inhibitor or a histamine H(2) receptor antagonist) is highly effective in healing the erosive oesophagitis lesion. However, numerous studies confirm that unless maintenance therapy is initiated virtually all patients will experience oesophagitis relapse within 1 year, as well as an increasing severity of oesophagitis and risk for complications such as Barrett's oesophagus and adenocarcinoma. Studies evaluating the efficacy of proton pump inhibitor and H(2) antagonist maintenance therapy have found that only the proton pump inhibitors significantly reduce the incidence of oesophagitis relapse. Pharmacoeconomic studies have also confirmed that proton pump inhibitor maintenance therapy is cost effective, by virtue of the ability of these agents to reduce the incidence of relapse as well as prolong the time to relapse and increase the number of weeks per year that patients are without symptoms. Lansoprazole, a member of the proton pump inhibitor class of agents, has been extensively studied in the treatment of patients with a variety of acid-related disorders. Among those with erosive oesophagitis, maintenance therapy with lansoprazole 15 or 30mg once daily is highly effective in preventing relapse. Studies have documented that lansoprazole 15 and 30mg once daily for six months prevents oesophagitis relapse in up to 81 and 93% of patients, respectively, with comparable percentages of patients remaining in remission after 1 year of treatment. These high rates of remission have also been observed in studies of patients with lesions that were difficult to heal at baseline (resistant to healing with at least 3 months of H(2) antagonist therapy). Moreover, lansoprazole produces high remission rates regardless of the grade of erosive oesophagitis before acute healing. Among symptomatic patients with heartburn, lansoprazole provides rapid and effective relief of daytime and night-time heartburn and prevents relapse of symptoms. Lansoprazole has a wide margin of safety and is well tolerated when administered as monotherapy in short- and long-term clinical trials. Taken together these data suggest that proton pump inhibitor therapy represents the preferred and ideal long-term management strategy for the patient with erosive oesophagitis. Lansoprazole is a well-established member of this class of agents and, as such, has an extensive body of literature that supports its safety, tolerability and clinical efficacy in preventing relapse in these patients.

Economic evaluation of long-term management strategies for erosive oesophagitis.

To compare the expected costs and outcomes of alternative strategies for the management of patients with erosive oesophagitis. There were 3 components to the overall analytic approach. First, a decision model was constructed to compare expected costs and outcomes of 6 management strategies. Second, principles of quantitative literature review and meta-analysis were used to determine probabilities of clinical events (i.e. oesophagitis healing and recurrence). Finally, principles of cost-effectiveness analysis were used to compare treatment alternatives in terms of dominance and incremental cost effectiveness. The viewpoint for the study was that of a provincial government payer for healthcare over a 1-year period. Healing rates were significantly higher for proton pump inhibitors (PPI) [p < 0.001]. Recurrence rates were significantly higher for intermittent therapy (placebo) and lower for regular dose PPI (p < 0.001). Maintenance prokinetic agent (PA) is dominated (i.e. more costly and less effective) and step-down maintenance PPI is dominated through principles of extended dominance. The 'efficient frontier' is represented by: maintenance H2-receptor antagonist (H2RA), intermittent PPI, step-down maintenance H2RA and maintenance PPI. The price of H2RA is a key factor influencing whether step-down maintenance PPI forms part of, or is contained within, the 'efficient frontier' of long term management for erosive oesophagitis.

Review article: current practice and future perspectives in the management of gastro-oesophageal reflux disease.

Gastro-oesophageal reflux disease (GERD) is primarily due to incompetence of the lower oesophageal sphincter (LOS) and crural diaphragm, with transient LOS relaxation frequently accounting for daytime reflux. In the absence of drugs that adequately correct the motility defects of GERD, treatment is directed towards decreasing gastric acidity. Oesophageal healing is related to control of 24-h intragastric acidity, the degree of acid suppression and duration of treatment. H2-receptor antagonists are generally less effective in GERD than in peptic ulcer disease. While providing symptomatic relief in non-erosive GERD, they are often ineffective in healing erosive oesophagitis. Proton pump inhibitors provide more rapid and complete healing and symptom resolution. They are superior to H2-receptor antagonists in the long-term management of erosive oesophagitis and in reducing recurrence of oesophageal stricture following mechanical dilatation. In Barrett's oesophagus, high-dose proton pump inhibitors in combination with laser/photodynamic ablation therapy can produce metaplastic regression, although this does not preclude future emergence of adenocarcinoma. Surgical morbidity and mortality rates in GERD generally remain higher than those associated with long-term pharmacotherapy. However, direct comparisons between laparascopic anti-reflux surgery and proton pump inhibitor maintenance therapy remain to be performed. Although there is no evidence that H. pylori infection worsens the severity of oesophagitis or that H. pylori is carcinogenic in the metaplastic oesophageal mucosa. It has been suggested that H. pylori-positive patients requiring long-term proton pump inhibitor therapy receive bacterial eradication therapy to reduce the risk of developing atrophic gastritis.

Prevention of Recurrences of Erosive Reflux Esophagitis: A Cost-Effectiveness Analysis of Maintenance Proton Pump Inhibition

PURPOSE: To determine the cost-effectiveness of three management strategies for healed erosive reflux esophagitis: maintenance therapy with a proton pump inhibitor (PPI) from the outset; no maintenance therapy unless a patient's symptoms recur once over a year; and no maintenance therapy unless a patient's symptoms recur twice over a year.MATERIALS AND METHODS: Decision analysis using data from randomized trials of lansoprazole, case series, and expert opinion.RESULTS: For patients with grade 4 esophagitis, maintenance from the outset is the most efficient approach. For all other patients, providing maintenance PPI after a patient experiences two recurrences is the least costly but least effective approach. The other two approaches prevent more recurrences: waiting to initiate maintenance therapy until symptoms recur once requires an additional $73 for each recurrence prevented whereas maintenance PPI from the outset requires an additional $819 for each recurrence prevented. Maintenance therapy from the outset is cost effective if symptoms of esophagitis cause a 22% or greater decrement in quality of life (using $50,000 per quality-adjusted life year gained as a cost-effectiveness definition). However, withholding maintenance until the time of a first recurrence is cost effective if symptoms cause a 2% or greater decrement in quality of life.CONCLUSION: For grades 2 and 3 esophagitis, providing maintenance therapy after a patient experiences a further recurrence is a preferred option that appears cost-effective across a wide array of assumptions. Maintenance therapy from the outset, however, appears cost-effective only for those patients who report a significant decline in quality of life associated with esophagitis or for those patients with baseline grade 4 esophagitis.