Goodnight GORD! Getting a better night’s sleep with GORD

Gastro-oesophageal reflux disease, or GORD, is one of the most common diseases affecting the adult population, especially the elderly. Up until now, it has been hard to gauge the effectiveness of treatment from the perspective of the patient. This area has been under investigation and a recently published paper in the Journal of Clinical Drug Investigation has compared two leading proton pump inhibitors (PPIs) using a newly devised questionnaire aimed at understanding their effectiveness, and whether complete remission of GORD is achievable. Using the comprehensive ReQuest questionnaire, the PPIs pantoprazole (Somac) and esomeprazole (Nexium) were assessed on many factors including relief of symptoms, effect on night-time symptoms as well as immediacy of effect. In most of the fields compared, pantoprazole (Somac) was found to be at least equally effective, if not more so (in the area of night time symptoms) than esomperazole and therefore should be considered as first line therapy for sufferers of GORD, and the more serious progressive diseases such as erosive GORD and erosive oesophagitis.1,2

Gastroesophageal reflux disease (GORD) is a chronic disease that commonly progresses to a range of potentially serious oesophageal complications such as oesophageal ulcers through to oesophageal cancer. It is characterized by reflux of the stomach contents into the oesophagus, oropharynx, larynx, or airway and is associated with heartburn, acid regurgitation, and dyspepsia. Gastroesophageal reflux disease is one of the most common chronic gastrointestinal disorders. It has been reported that GORD affects up to one-third of adults.^1,2

Adequate treatment of this disease and its complications should either prevent repeated reflux of gastric contents into the oesophagus or reduce the damaging effect of gastric acid. As no pharmaceutical agent can fully correct the motor dysfunction responsible for acid reflux into the oesophagus, acid suppression remains the most effective way to relieve symptoms and to promote healing of oesophagitis in patients with GORD.

Gastro-oesophageal reflux disease (GORD) is associated with varying symptoms that may be typical or atypical of the disease and that may be accompanied by erosive oesophagitis. Symptoms are troublesome for patients and, at times, can impact on their lifestyles and rest.

Most troubling for many patients are how the GORD symptoms affect them at night. They may be awoken with feelings of pain, nausea, dyspepsia or a constant cough. The discomfort caused can severely disrupt sleep for many, and this can result in day-time suffering for the GORD patient. Therefore, any medication that can decrease these symptoms are favoured in treatment.

Assessment of symptoms using developed scales have been employed to assess response to treatment in GORD clinical trials. Typically they do not account for the heterogeneous, episodic nature of GORD and the poor correlation between patients’ and physicians’ assessment of symptoms. The ReQuest^TM questionnaire permits self-assessment of changes on a broad range of GORD-related symptoms on a daily basis. Two popular PPIs currently available for the first line treatment of GORD are the first two pharmaceutical agents that have been comprehensively surveyed using the new ReQuest questionnaire assessment tool.

In a study in which 529 intention-to-treat (ITT) patients with GORD were randomised to 4 weeks’ trial of a PPI in treatment with pantoprazole 20 mg/day or esomeprazole 20 mg/day and where symptom scales were employed, daily assessment of ReQuest^TM symptom scores revealed that the two PPIs were equally effective with regard to both first and sustained symptom relief. The first-dose effects of pantoprazole and esomeprazole have also been investigated with regard to the intensity and frequency of acid episodes.

Early findings from a large field trial of pantoprazole 40mg once daily for 4 weeks using daily symptom assessment with Re Quest in Practice^TM in >3300 patients recruited by >1800 doctors showed that pantoprazole significantly improved GORD-associated symptoms from day 2 onwards. Patients who were treated with a 4 week course of pantoprazole reported less symptoms and relapses after treatment than those treated with esomeprazole. This suggests that pantoprazole may be particularly suitable for on-demand treatment for GORD.

In patients with more severe disease, such as erosive oesophagitis, pantoprazole was reported to be more effective at decreasing the intensity of symptoms such as dyspepsia, and dyspepsia at night which may lead to waking episodes, disturbing sleep.

Therefore, using the ReQuest questionnaire in recent trials, it has been shown that PPIs such as pantoprazole and esomeprazole should still be used as first line treatment in GORD. This evidence has proven pantoprazole to be equally adequate with esomeprazole in symptom relief. Furthermore, pantoprazole may also be better than esomeprazole at decreasing bothersome night-time symptoms and can be used as on-demand PPI therapy.  

Reference:

1. Thomson ABR. The concept of complete remission of gastro-oesophageal reflux disease comparative efficacy of pantoprazole and esomeprazole using the ReQuest^TM Questionnaire. Clin Drug Invest 2007; 27(10): 663-72.
2. Kumar P, Clark M. Clinical Medicine, 5th Edition, 2003, WB Saunders, London
3. Scholen T. Long-term management of gastroesophageal reflux disease with pantoprazole. Therapeutics and Clinical Risk Management 2007; 3(2): 231-43.