Nocturnal acid breakthrough - approach to management

Abstract

Nocturnal acid breakthrough is defined as the presence of intragastric pH < 4 during the overnight period for at least 60 continuous minutes in patients taking a proton-pump inhibitor (PPI). Nocturnal acid breakthrough occurs in more than 70% of Helicobacter pylori-negative patients on PPI therapy and has clinical consequences in particular in patients with complicated gastroesophageal reflux disease (GERD), Barrett's esophagus, and esophageal motility abnormalities. The clinical importance of nocturnal acid breakthrough and the benefit of adding histamine-2 receptor antagonists (H2RAs) to PPI therapy have been debated ever since these concepts were introduced. In our experience, the addition of bedtime H2RAs is clinically effective in controlling nocturnal acid breakthrough and GERD symptoms.

Figure 1

Twenty-four-hour intragastric pH profiles of daily-dosed PPIs. Note the beginning of nocturnal acid breakthrough between 9:00 and 10:00 PM for all PPIs.[7] Key: Ome 20 = omeprazole 20 mg (oral) every morning; Lanso 30 = lansoprazole 30 mg (oral) every morning; Panto 40 = pantoprazole 40 mg (oral) every morning; Rabe 20 = rabeprazole 20 mg (oral) every morning.