title: Concomitant irritable bowel syndrome is associated with failure of step-down on-demand proton pump inhibitor treatment in patients with gastro-esophageal reflux disease.
abstract: BACKGROUND
  The predictors for treatment failure of on-demand proton pump inhibitor (PPI) therapy in gastro-esophageal reflux disease (GERD) patients are unclear. We studied the efficacy and predictors for treatment failure of step-down on-demand PPI therapy in patients with non-erosive reflux disease (NERD) and those with low grade erosive esophagitis.
  
  
  METHODS
  Consecutive symptomatic GERD patients who had positive esophageal pH studies and complete symptom resolution with initial treatment of esomeprazole were given step-down on-demand esomeprazole for 26 weeks. Patients with esophagitis of Los Angeles (LA) grade C or above and recent use of PPI were excluded. Treatment failure was defined as an inadequate relief of reflux symptoms using global symptom assessment. Potential predictors of treatment failure were determined using multivariate analysis.
  
  
  RESULTS
  One hundred and sixty three NERD and 102 esophagitis patients were studied. The 26-week probability of treatment failure was 36.2% (95% CI: 23.9-46.5%) in NERD group and 20.1% (95% CI: 10.9-28.3%) in esophagitis group, respectively (P = 0.021). Irritable bowel syndrome (adjusted HR: 2.1, 95% CI: 1.5-3.8, P = 0.01), in addition to daily reflux symptom (adjusted hazard ratio: 2.7, 95% CI: 1.9-4.2, P = 0.001) and concomitant dyspepsia (adjusted hazard ratio: 1.7, 95% CI: 1.1-2.8, P = 0.04), were independent predictors for treatment failure.
  
  
  CONCLUSIONS
  Compared to patients with esophagitis, NERD patients have higher failure rate of on-demand PPI therapy. Concomitant irritable bowel syndrome, in addition to daily reflux symptom and dyspepsia, is associated with the failure of on-demand PPI in these patients.
authors.affiliation: Institute of Digestive Disease, The Chinese University of Hong Kong, Shatin, Hong Kong. justinwu@cuhk.edu.hk
authors.forename: J C Y
authors.initials: JC
authors.lastname: Wu
authors.forename: L H
authors.initials: LH
authors.lastname: Lai
authors.forename: D K L
authors.initials: DK
authors.lastname: Chow
authors.forename: G L H
authors.initials: GL
authors.lastname: Wong
authors.forename: J J Y
authors.initials: JJ
authors.lastname: Sung
authors.forename: F K L
authors.initials: FK
authors.lastname: Chan
mesh_terms: D000328:Adult; D015331:Cohort Studies; D015897:Comorbidity; D064098:Esomeprazole / Q000627:therapeutic use*; D004942:Esophagitis, Peptic / Q000188:drug therapy / Q000453:epidemiology; D005260:Female; D005764:Gastroesophageal Reflux / Q000188:drug therapy* / Q000453:epidemiology*; D006801:Humans; D006863:Hydrogen-Ion Concentration; D043183:Irritable Bowel Syndrome / Q000453:epidemiology*; D008137:Longitudinal Studies; D008297:Male; D008365:Manometry; D008875:Middle Aged; D015999:Multivariate Analysis; D011237:Predictive Value of Tests; D011446:Prospective Studies; D054328:Proton Pump Inhibitors / Q000627:therapeutic use*; D012189:Retrospective Studies; D017211:Treatment Failure
chemical_list: D054328:Proton Pump Inhibitors; D064098:Esomeprazole