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117 A SYSTEMATIC REVIEW OF HIGH- VERSUS STANDARD-DOSE PROTON PUMP INHIBITOR THERAPY IN HEALING ESOPHAGITIS M Khan1, J Santana1, C Donellan2, C Preston2, P Moayyedi1 INTRODUCTION: Systematic reviews suggest proton pump inhibitors (PPIs) are the most effective medical therapy for GERD. Some GERD patients, however, do not respond to standard dose PPI therapy and a common practice is to double the dose. The efficacy of this strategy is uncertain and is also unclear whether there is any difference between different types of PPIs. We therefore evaluated the efficacy of double dose versus standard dose PPI therapy in patients with esophagitis in a Cochrane systematic review.
1Division of Gastroenterology, McMaster University, Hamilton, Ontario; 2Gastroenterology Unit, Leeds General Infirmary, Leeds, United Kingdom
METHODS: We conducted a search of electronic databases (Medline, Cinhal, Embase and Cochrane controlled trials register) to May 2005. We also performed a recursive search of literature from identified articles. All randomized control trials (RCTs) in adult patients with endoscopically proven esophagitis comparing standard dose with double dose PPI for four to eight weeks were eligible. Eligibility check and data extraction were performed by two independent reviewers and discrepancies if any were resolved by a third reviewer. Results were expressed as relative risk of esophagitis persisting in the double dose versus standard dose PPI groups. Meta analysis was performed using a DerSimonian and Laird random effects model.
RESULTS: We identified 14 articles evaluating 11,497 esophagitis patients. Overall esophagitis persistence in high-dose group (22.6%) was lower than in standard-dose group. (28.7%), but the difference was not statistically significant. (RR of persistence at four weeks = 0.89, 95% CI 0.76 to 1.04) with a number needed to treat of 33 (95% CI benefit 14 to harm 100). Overall symptoms persisted in 25.6% patients in the group taking a high dose of PPIs, compared with 23.1% in the standard dose group and this difference was not statistically significant (RR of persistence at four weeks = 1.06, 95% CI 0.90 to 1.25) with a number needed to harm of 100 (95% CI harm 25 to benefit 50). A subgroup analysis of trials that evaluated esomeprazole 40 mg once daily showed statistically significant effect on esophagitis healing (RR of esophagitis persistence = 0.75, 95% CI 0.62 to 0.9) compared with standard dose PPI therapy. There was statistically significant heterogeneity between studies (
CONCLUSION: These data do not support the practice of doubling the dose of PPI therapy in patients that do not respond to standard dose therapy with PPIs other than esomeprazole.