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Meta-Analysis
. 2013 May 31;2013(5):CD002095.
doi: 10.1002/14651858.CD002095.pub5.

Short-term treatment with proton pump inhibitors, H2-receptor antagonists and prokinetics for gastro-oesophageal reflux disease-like symptoms and endoscopy negative reflux disease

Kirsten E Sigterman  1 , Bart van Pinxteren, Peter A Bonis, Joseph Lau, Mattijs E Numans
Affiliations
Meta-Analysis

Short-term treatment with proton pump inhibitors, H2-receptor antagonists and prokinetics for gastro-oesophageal reflux disease-like symptoms and endoscopy negative reflux disease

Kirsten E Sigterman et al. Cochrane Database Syst Rev. .

Abstract

Background: Approximately 25% of adults regularly experience heartburn, a symptom of gastro-oesophageal reflux disease (GORD). Most patients are treated empirically (without specific diagnostic evaluation e.g. endoscopy. Among patients who have an upper endoscopy, findings range from a normal appearance, mild erythema to severe oesophagitis with stricture formation. Patients without visible damage to the oesophagus have endoscopy negative reflux disease (ENRD). The pathogenesis of ENRD, and its response to treatment may differ from GORD with oesophagitis.

Objectives: Summarise, quantify and compare the efficacy of short-term use of proton pump inhibitors (PPI), H2-receptor antagonists (H2RA) and prokinetics in adults with GORD, treated empirically and in those with endoscopy negative reflux disease (ENRD).

Search methods: We searched MEDLINE (January 1966 to November 2011), EMBASE (January 1988 to November 2011), and EBMR in November 2011.

Selection criteria: Randomised controlled trials reporting symptomatic outcome after short-term treatment for GORD using proton pump inhibitors, H2-receptor antagonists or prokinetic agents. Participants had to be either from an empirical treatment group (no endoscopy used in treatment allocation) or from an endoscopy negative reflux disease group (no signs of erosive oesophagitis).

Data collection and analysis: Two authors independently assessed trial quality and extracted data.

Main results: Thirty-four trials (1314 participants) were included: fifteen in the empirical treatment group, fifteen in the ENRD group and four in both. In empirical treatment of GORD the risk ratio (RR) for heartburn remission (the primary efficacy variable) in placebo-controlled trials for PPI was 0.37 (two trials, 95% confidence interval (CI) 0.32 to 0.44), for H2RAs 0.77 (two trials, 95% CI 0.60 to 0.99) and for prokinetics 0.86 (one trial, 95% CI 0.73 to 1.01). In a direct comparison PPIs were more effective than H2RAs (seven trials, RR 0.66, 95% CI 0.60 to 0.73) and prokinetics (two trials, RR 0.53, 95% CI 0.32 to 0.87).In treatment of ENRD, the RR for heartburn remission for PPI versus placebo was 0.71 (ten trials, 95% CI 0.65 to 0.78) and for H2RA versus placebo was 0.84 (two trials, 95% CI 0.74 to 0.95). The RR for PPI versus H2RA was 0.78 (three trials, 95% CI 0.62 to 0.97) and for PPI versus prokinetic 0.72 (one trial, 95% CI 0.56 to 0.92).

Authors' conclusions: PPIs are more effective than H2RAs in relieving heartburn in patients with GORD who are treated empirically and in those with ENRD, although the magnitude of benefit is greater for those treated empirically.

PubMed Disclaimer

Conflict of interest statement

None known.

Figures

1
1
Study flow diagram.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Forest plot of comparison: 1 PPI versus placebo, outcome: 1.1 Heartburn remission.
4
4
Forest plot of comparison: 2 H2RA versus placebo, outcome: 2.1 Heartburn remission.
5
5
Forest plot of comparison: 4 PPI versus H2RA, outcome: 4.1 Heartburn remission.
1.1
1.1. Analysis
Comparison 1 PPI versus placebo, Outcome 1 Heartburn remission.
1.2
1.2. Analysis
Comparison 1 PPI versus placebo, Outcome 2 Overall improvement.
2.1
2.1. Analysis
Comparison 2 H2RA versus placebo, Outcome 1 Heartburn remission.
2.2
2.2. Analysis
Comparison 2 H2RA versus placebo, Outcome 2 Painfree at day.
2.3
2.3. Analysis
Comparison 2 H2RA versus placebo, Outcome 3 Painfree at night.
2.4
2.4. Analysis
Comparison 2 H2RA versus placebo, Outcome 4 Overall improvement.
3.1
3.1. Analysis
Comparison 3 Prokinetic versus placebo, Outcome 1 Heartburn remission.
3.2
3.2. Analysis
Comparison 3 Prokinetic versus placebo, Outcome 2 Painfree at day.
3.3
3.3. Analysis
Comparison 3 Prokinetic versus placebo, Outcome 3 Painfree at night.
3.4
3.4. Analysis
Comparison 3 Prokinetic versus placebo, Outcome 4 Overall improvement.
4.1
4.1. Analysis
Comparison 4 PPI versus H2RA, Outcome 1 Heartburn remission.
4.2
4.2. Analysis
Comparison 4 PPI versus H2RA, Outcome 2 Overall improvement.
5.1
5.1. Analysis
Comparison 5 PPI versus prokinetic, Outcome 1 Heartburn remission.
6.1
6.1. Analysis
Comparison 6 H2RA versus prokinetic, Outcome 1 Painfree at day.
See this image and copyright information in PMC

Update of

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References to other published versions of this review

Van Pinxteren 2004
    1. Pinxteren B, Numans ME, Bonis P, Lau J. Short‐term treatment with proton pump inhibitors, H2‐receptor antagonists and prokinetics for gastro‐oesophageal reflux disease‐like symptoms and endoscopy negative reflux disease. Cochrane Database of Systematic Reviews 2004, Issue 2. [DOI: 10.1002/14651858.CD002095] - DOI - PubMed
Van Pinxteren 2006
    1. Pinxteren B, Numans ME, Bonis P, Lau J. Short‐term treatment with proton pump inhibitors, H2‐receptor antagonists and prokinetics for gastro‐oesophageal reflux disease‐like symptoms and endoscopy negative reflux disease. Cochrane Database of Systematic Reviews 2006, Issue 3. [DOI: 10.1002/14651858.CD002095.pub2] - DOI - PubMed
Van Pinxteren 2010a
    1. Pinxteren B, Sigterman KE, Bonis P, Lau J, Numans ME. Short‐term treatment with proton pump inhibitors, H2‐receptor antagonists and prokinetics for gastro‐oesophageal reflux disease‐like symptoms and endoscopy negative reflux disease. Cochrane Database of Systematic Reviews 2010, Issue 1. [DOI: 10.1002/14651858.CD002095.pub3] - DOI - PubMed
Van Pixteren 2010b
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