Cisapride treatment for gastro-oesophageal reflux in children.
BACKGROUND
Gastro-oesophageal reflux (GOR) is an extremely common and usually self-limiting condition in infants. When treatment is required, Cisapride, a pro-kinetic agent, has been commonly prescribed for the symptomatic management of GOR. There have been recent reports of possibly serious adverse events, e.g. an increased QTc interval, cardiac arrhythmias, and death, associated with the use of Cisapride.


OBJECTIVE
To determine the effectiveness of Cisapride for symptoms of GOR compared with placebo or any other non-surgical treatments.


METHODS
Searches were conducted of the Cochrane Central Trials Register and the specialised Trials register of the Cochrane Upper Gastrointestinal and Pancreatic Diseases Group, MEDLINE and Embase up till April 2002. Reference lists of relevant review articles and identified trials were scrutinised and forward citation searches were performed in the Science Citation Index on all trials identified.


METHODS
Randomised controlled trials that compared oral Cisapride therapy with placebo or with other non-surgical treatments for children with a diagnosis of GOR were included. Only studies in which Cisapride was administered orally for a minimum of one week and which documented at least one of the primary outcomes were included. We excluded trials in which the majority of participants were aged less than 28 days.


METHODS
The primary outcomes were defined as a change in symptoms at the end of treatment, presence of adverse events, occurrence of clinical complications, and weight gain. The secondary outcomes included physiological measures of GOR or histological evidence of oesophagitis. We dichotomised symptoms into 'same or worse' vs 'improved' and calculated summary odds ratios. Continuous measures of GOR (e.g. reflux index) were summarised as a weighted mean difference. All outcomes were analysed using a random effects method.


RESULTS
Searches identified nine trials which met the inclusion criteria. Eight trials compared Cisapride with placebo, of which seven (236 participants) reported data on symptoms of gastro-oesophageal reflux, and one reported data on the QTc interval (49 patients). The odds ratio for 'same or worse' vs 'improved symptoms' at the end of treatment of 0.34 (95%CI 0.10, 1.19) did not show a statistically significant difference between the two interventions. There was significant heterogeneity between the studies and the funnel plot suggested publication bias. In a sensitivity analysis, the definition of outcomes was changed to 'any symptoms' vs 'no symptoms'. This resulted in the exclusion of three trials (one of them the largest, best quality trial). The resulting pooled odds ratio showed a significant effect of Cisapride (OR 0.19, 95%CI 0.08, 0.44). Five studies reported adverse events. Four reported adverse events (mainly diarrhoea) but the difference was not statistically significant (OR 1.80, 95%CI 0.87, 3.70). One trial found no difference in the QTc after 3 to 8 weeks of treatment. Cisapride was associated with a statistically significant reduction in the reflux index (weighted mean difference -6.49, 95%CI -10.13, -2.85), but as reflux index and clinical symptoms are poorly correlated, the clinical importance of this finding is uncertain. Other measures of oesophageal pH monitoring did not reach significance. One included study compared Cisapride with Gaviscon (or Gaviscon and Carobel). The odds ratio for 'same or worse' vs 'improvement' in the Cisapride group compared with Gaviscon was 3.26 (95%CI 0.93-11.38).


CONCLUSIONS
We found no clear evidence that Cisapride reduces symptoms of GOR. The results suggested substantial publication bias favouring studies showing a positive effect of Cisapride. This finding is supported by the report of one unpublished multi-centre study of 134 patients, which was reported to show no evidence of a significant effect of Cisapride. Due to reports of fatal cardiac arrhythmias or sudden death, from July 2000, cisapride was restricted to a limited access programme supervised by a paediatric gasterologist in the USA and in Europe, to patients treated within a clinical trial or safety study or registry programme. CHECK WITH MCA WHAT THEY SAY ABOUT CISAPRIDE IN THE USA. OTHER COUNTRIES?
Epidemiology and Public Health, Institute of Child Health, 30 Guilford Street, London, UK, WC1N 1EH. C.Augood@ich.ucl.ac.uk
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D000897:Anti-Ulcer Agents / Q000627:therapeutic use*; D020117:Cisapride / Q000627:therapeutic use*; D005764:Gastroesophageal Reflux / Q000188:drug therapy*; D005765:Gastrointestinal Agents / Q000627:therapeutic use*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D016032:Randomized Controlled Trials as Topic
D000897:Anti-Ulcer Agents; D005765:Gastrointestinal Agents; D020117:Cisapride