Once-Daily Omeprazole/Sodium Bicarbonate Heals Severe Refractory Reflux Esophagitis with Morning or Nighttime Dosing

Abstract

Background

Morning dose or twice-daily proton pump inhibitor (PPI) use is often prescribed to heal severe reflux esophagitis.

Aim

Compare the effect of single dose morning (control arm) versus nighttime (experimental arm) omeprazole/sodium bicarbonate (Zegerid^®) (IR-OME) on esophagitis and gastroesophageal reflux symptoms.

Methods

Adult outpatients with Los Angeles grade C or D esophagitis were allocated to open-label 40 mg IR-OME once a day for 8 weeks in a prospective, randomized, parallel design, single center study. Esophagogastroduodenoscopy (EGD) and validated self-report symptom questionnaires were completed at baseline and follow-up. Intention-to-treat and per-protocol analyses were performed.

Results

Ninety-two of 128 (72 %) eligible subjects participated [64 (70 %) male, mean age 58 (range 19–86), median BMI 29 (range 21–51), 58 C:34 D]. Overall, 81 (88 %) subjects healed [n = 70 (76 %)] or improved [n = 11 (12 %)] erosions. There was no significant difference (morning vs. night) in mucosal healing [81 vs. 71 %, (p = 0.44)] or symptom resolution [heartburn (77 vs. 65 %, p = 0.12), acid regurgitation (82 vs. 73 %, p = 0.28)]. Prevalence of newly identified Barrett’s esophagus was 14 % with half diagnosed only after treatment.

Conclusions

Once-daily IR-OME (taken morning or night) effectively heals severe reflux esophagitis and improves GERD symptoms. Results support the clinical practice recommendation to repeat EGD after 8 weeks PPI therapy in severe esophagitis patients to assure healing and exclude Barrett’s esophagus.

Appendix

• 1. Hypotheses and aims

  • A priori hypotheses:

    • The timing of administration of omeprazole/sodium bicarbonate will impact its efficacy in healing esophagitis

    • Nighttime administration (experimental arm) will be superior in healing esophagitis compared to morning administration (control arm) prior to a meal.

  • A priori primary aim: quantify the efficacy of omeprazole/sodium bicarbonate in healing severe erosive esophagitis when used either as a morning or before bedtime dose.

  • A priori secondary aims:

    • Determine the percent of patients who improve, but did not resolve, their mucosal damage.

    • Determine the efficacy of omeprazole/sodium bicarbonate on symptom resolution in patients with erosive esophagitis

    • Assess the frequency with which a diagnosis of Barrett’s esophagus was made once the overlying severe esophagitis had healed.

  • A priori exploratory and hypothesis-generating objective: assess objective control of esophageal acid exposure as determined by ambulatory pH monitoring.

• 2. IR-OME powder instruction details

Omeprazole/sodium bicarbonate powder for oral suspension 40 mg was supplied in individual packets that are emptied into a small cup containing 15–30 ml (1–2 tablespoons) of water, one per day, for 8 weeks. They were asked to stir well and drink immediately then refill the cup with water and drink. Subjects assigned to morning dosing were instructed to take the medication on an empty stomach, immediately upon rising, 20–60 min prior to chewing a solid. Subjects assigned to nighttime dosing were instructed to keep the medication by their bedside; taking the medication in a standing or seated upright position immediately before turning off the lights with the intention to sleep. The subject was instructed to not use other liquids or foods for 20 min after taking their study medication for those allocated to morning dosing, and until the next morning for those allocated to nighttime dosing.

• 3. Endoscopic outcomes

LA classification system [1]

• LA grade A: one or more erosions on non-confluent folds in which the longest erosion is <5 mm length

• LA grade B: one or more erosions on non-confluent folds in which the longest erosion is ≥5 mm length

• LA grade C: confluent erosions of more than one fold involving <75 % of the circumference.

• LA grade D: confluent erosions involving ≥75 % of the circumference of the distal esophagus.

The endoscopic evaluation results were grouped for outcomes analysis as follows, for subjects with:

• LA C esophagitis at baseline:

  • Healed = no erosions in the esophagus

  • Improved = LA grades A or B

  • Same or worse = C or D at follow-up

• LA D esophagitis at baseline:

  • Healed = no erosions in the esophagus

  • Improved = LA grades A, B or C

  • Same = LA grade D at follow-up

• 4. MDQ-30 scoring details

  • Symptom analysis: GERD symptoms (absent, infrequent, frequent) at baseline and follow-up were measured by the MDQ-30.

    • Frequent: The respondent reports experiencing heartburn, (a burning pain or discomfort behind the breast bone in the chest), at least once per week, with at least one of the following: heartburn that improves with antacids, awakens them at night, or radiates to the neck. Respondents would also be categorized as having frequent GERD symptoms if they report experiencing acid regurgitation, (a bitter or sour-tasting fluid coming up from the stomach into the mouth or throat), at least once per week.

    • Absent: The respondent is completely asymptomatic; denies experiencing heartburn or acid regurgitation.

    • Infrequent: Any heartburn or acid regurgitation in those who do not meet criteria for frequent symptoms.

  • Symptom outcomes at follow-up include:

    • Complete resolution (subjects with either frequent or infrequent GERD symptoms at baseline report the absence of GERD symptoms at follow-up)

    • Partial resolution (subjects with frequent GERD symptoms at baseline meet criteria for infrequent GERD symptoms at follow-up)

    • No improvement (subjects with either frequent or infrequent GERD symptoms at baseline continue to report those symptoms at follow-up)

• 5. Per-protocol demographic results (Table 5)

  Table 5 Subject demographics at baseline, per-protocol analysis

• 6. Table 6 is an ITT (worst case) version of Table 2. Table 6 was not used in the body of the manuscript because there was imbalance in the subjects who completed their questionnaires. Nine subjects allocated to nighttime IR-OME dosing, compared to 3 subjects allocated to morning dosing did not fully complete their follow-up questionnaires. In the ITT analysis, we assume subjects without follow-up questionnaire information have severe symptoms at follow-up. Thus, the statistically significant findings shown in Table 6 are artifactual. Thus, we opted to show the Per-protocol results in the manuscript (see Table 2).

  Table 6 Frequency of heartburn, acid regurgitation and overall GERD symptoms in subjects allocated to morning (n = 43) versus nighttime (n = 49) dosing of omeprazole/sodium bicarbonate at entry and following 8 weeks therapy, intention-to-treat analysis (worst case)

• 7. Table 7 is the ITT (best case) version of Table 2. It shows the results for ITT best case scenario in which we assume subjects without follow-up questionnaire information are symptom free at 8 weeks.

  Table 7 Frequency of heartburn, acid regurgitation and overall GERD symptoms in subjects allocated to morning (n = 43) versus nighttime (n = 49) dosing of omeprazole/sodium bicarbonate at entry and following 8 weeks therapy, Intention-To-Treat analysis (best case)

• 8. Detailed demographic information of 13 subjects ultimately diagnosed with Barrett’s esophagus (Table 8).

  Table 8 Endoscopic features of subjects ultimately diagnosed with Barrett’s esophagus showing raw symptom, sex, age and Body Mass Index (BMI) data

Fig. 4

a Frequency of heartburn before and after 8 weeks of omeprazole/sodium bicarbonate therapy comparing morning versus nighttime dosing. Intention-to-treat (worst case). b Frequency of acid regurgitation before and after 8 weeks of omeprazole/sodium bicarbonate therapy comparing morning versus nighttime dosing. Intention-to-treat (worst case)

Fig. 5

a Frequency of heartburn before and after 8 weeks of omeprazole/sodium bicarbonate therapy comparing morning versus nighttime dosing. Intention-to-treat (best case). b Frequency of acid regurgitation before and after 8 weeks of omeprazole/sodium bicarbonate therapy comparing morning versus nighttime dosing. Intention-to-treat (best case)