Managing Night Time GERD: Comparative Review of Efficacy of esomeprazole against conventional PPIs

Proton Pump Inhibitors (PPI) are the first choice drugs for treating GERD, along with its associated symptoms. (4,5) While traditional PPIs like Lansoprazole, Omeprazole, Pantoprazole have been in use for a long time, recent studies have highlighted that their use comes with their limitations and side effects. (6, 7)

Esomeprazole, a relatively newer PPI, has been introduced as the first PPI with a single active optical isomer, making it more efficacious in acid suppression and thus, combating GERD. Esomeprazole is metabolically more stable and leads to higher bioavailability and an increase in the area under the plasma concentration-time curve (AUC). Hence, it provides more effective control over gastric acid secretions, when compared to other PPI therapy. Differing from its predecessor Omeprazole by virtue of its novel molecular construction, growing evidence suggests this drug has an edge over other available PPIs in combating GERD. (8, 9)

Is Esomeprazole better than traditional PPIs?

Managing nighttime GERD- Exhibiting clear supremacy in controlling esophageal and gastric acid secretions than other PPIs (10), Esomeprazole is a more potent drug in managing nocturnal GERD.

• Esomeprazole vs lansoprazole- Shedding light on the efficacy and activity of esomeprazole on intra-esophageal pH profiles when compared to PPIs, a study compared 40 mg of esomeprazole to 30 mg of lansoprazole in 30 patients with complicated GERD. (11) Results indicated that esomeprazole was superior to lansoprazole in both total (75% vs. 28%, P = 0.026) and supine position (93% vs. 50%, P=0.012) nocturnal esophageal acid exposure. Another study by Schmitt C et al noted that esomeprazole was superior to lansoprazole at 4 weeks (60.8% vs. 47.9%,P = 0.02) and 8 weeks (88.4% vs. 77.5%, P = 0.007) in patients with moderate to severe esophagitis(12) .Yet other trials have compared the effects of esomeprazole with other PPIs in erosive GERD, analyzing healing rates and GERD symptoms. The authors concluded that Esomeprazole (40 mg) exhibited a higher healing rate and was more effective than lansoprazole (30 mg) in resolving heartburn. (13)
• Esomeprazole vs Omeprazole- Affirming the superiority of esomeprazole, notable studies by Kahrilas PJ and Richter JE, indicated that esomeprazole had a higher healing rate and better symptom control than omeprazole in mild reflux esophagitis. (14,15) Research has further confirmed that esomeprazole holds its exceptional efficacy even in more severe esophagitis. (16)
• Esomeprazole vs pantoprazole- Studies comparing esomeprazole 40 mg with pantoprazole 40 mg and aimed at evaluating the healing in erosive oesophagitis concluded that esomeprazole had higher healing rates than pantoprazole at 4 weeks (81% vs. 75%) and 8 weeks (96% vs. 92%) and provided better resolution of GERD symptoms. (8,17)

Maintenance therapy of healed erosive GERD- Sustaining a symptomless and healed state after successful resolution of nocturnal GERD is as important as managing an acute episode.

• Esomeprazole vs. lansoprazole- Noteworthy studies by Devault et al and Lauritsen et al, aimed at evaluating the healing rate of erosive GERD at 6 months opined that esomeprazole was far more competent than lansoprazole with 84.8% vs. 75.9% and 83% vs. 74% patients healed of symptoms, respectively. (18) Esomeprazole (20 mg) was more effective in maintaining therapy than lansoprazole (15 mg) at 6 months, with endoscopy-confirmed healing (19). A similar second study found 83% of the esomeprazole group was in remission compared to 74% of the lansoprazole group, at 6 months, and more patients were symptom-free. (20)

• Esomeprazole vs. pantoprazole- Maintaining a healed state in erosive esophagitis for a longer period, along with relief of gastroesophageal symptoms, studies have affirmed that esomeprazole is superior to pantoprazole. (21) Heartburn relapse rates after esophagitis were also lower with esomeprazole.

Managing relapsing GERD- With a strikingly high relapse rate of 80 %, patients with severe erosive GERD, very often, revert to a compromised life within 12 months of discontinuing PPI therapy. (22) Such complicated scenarios warrant choosing a better PPI with a proven high success rate. A remarkable study by Jones et al, investigating the effectiveness of esomeprazole 40 mg in GERD symptoms persisting in patients even after receiving a full daily dose PPI, has concluded that treatment with esomeprazole 40 mg daily in such patients is associated with a significant reduction in symptoms within 4–8 weeks., both in frequency and severity. (23)

On-demand therapy- Esomeprazole (20 mg), as an on-demand therapy, was found to be economically and potentially more effective than lansoprazole 15 mg daily after 6 months in endoscopy-negative GERD. (24) The study further showed better symptom control with more patients willing to continue on-demand therapy than using lansoprazole on daily basis (93% vs. 88%).

Cost effectiveness-The success of on-demand therapy with esomeprazole resonates with the fact that treating GERD with this drug can lead to direct cost savings as against a continuous treatment with other PPIs. Further, considering the average wholesale prices, esomeprazole is priced at par with the other PPIs. (25)

Safety-Classified as a class B drug, esomeprazole is generally well-tolerated and regarded to be effective and safe during pregnancy. (10) Reproductive studies in animals have found no evidence of impaired fertility or harm to the fetus in subjects receiving the equivalent of or up to 57 times the human dosage. (25)

Though long-term or high-dose PPI therapy increases the risk of hip fracture, (26), the relationship between esomeprazole, fracture risk, and osteoporosis remains inconclusive.

Key pointers 

A decent knowledge of esomeprazole can go a long way in changing the scenario of treating nighttime GERD.

Esomeprazole maintains an intragastric PH above 4 for a longer time than other PPIs.

Esomeprazole 40 mg od for up to 8 weeks provided higher rates of healing of erosive GERD and a greater proportion of patients with sustained resolution of heartburn than omeprazole 20 mg, lansoprazole 30 mg, or pantoprazole 40 mg od.

Esomeprazole 20 mg od has also been shown to be more effective in maintaining healing of erosive GERD compared with lansoprazole 15 mg od or pantoprazole 20 mg od.

Conclusion-

Esmoprazole, a first-of-its-kind PPI, has revolutionized the management protocols for night-time GERD. Physicians should be aware of the new advances on this drug as research continues to reaffirm its supremacy. With more robust evidence supporting its potency in GERD, esomeprazole has cemented its position as the first choice over other available PPIs.

References:

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