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Addition of a H2 Receptor Antagonist to PPI Improves Acid Control and Decreases Nocturnal Acid Breakthrough

Mainie, Inder MRCP; Tutuian, Radu MD; Castell, Donald O. MD

Journal of Clinical Gastroenterology: July 2008 - Volume 42 - Issue 6 - p 676-679
doi: 10.1097/MCG.0b013e31814a4e5c
ALIMENTARY TRACT: Clinical Research

Background The addition of a bedtime H2 receptor antagonist (H2RA) to proton pump inhibitor (PPI) b.i.d. to inhibit nocturnal acid breakthrough (NAB) is controversial. H2RA tolerance has been documented suggesting limitations in its long-term effect.

Aim To compare the intragastric pH and NAB occurring with twice daily PPI with or without the addition of a H2RA.

Method Multichannel intraluminal impedance-pH studies in 100 patients were reviewed. Fifty-eight patients (female 41; mean age, 54 y; range, 17 to 85) were studied on twice daily PPI. Forty-two patients (female 36; mean age, 53 y; range 20 to 85) were studied on a PPI b.i.d.+H2RA for at least 1 month at bedtime. The percentage time of intragastric pH<4 (upright, recumbent, and total) and NAB were compared between the groups.

Results In the patients with PPI b.i.d. 64% had NAB, compared with only 17% of patients on PPI b.i.d. and H2RA q.h.s. (P<0.001). The percent time intragastric pH<4 for patients on PPI b.i.d. was significantly higher (P<0.01) compared with patients on PPI b.i.d.+H2RA q.h.s. during upright (29.1±3.0 vs. 18.3±2.9), recumbent (33.5±3.4 vs. 12.5±3.1), and entire period (31.5±2.8 vs. 18.0±3.0).

Conclusions The addition of a bedtime H2RA reduces the percentage time of the intragastric pH<4 and also NAB. H2RA should be considered as adjunct therapy in whom greater suppression of gastric acid control is considered desirable.

Division of Gastroenterology and Hepatology, Medical University South Carolina, Charleston, SC

The authors declare no conflict of interest.

The authors confirm that there is no financial arrangement with such drug, appliance, or treatment or its competitor and there are no financial interests that might have an impact on the views expressed in the article, editorial, letter, or commentary.

Reprints: Donald O. Castell, MD, Division of Gastroenterology/Hepatology, Medical University of South Carolina, 96 Jonathan Lucas Street, 210 CSB, Charleston, SC 29425 (e-mail:

Received for publication December 28, 2006; accepted June 28, 2007

© 2008 Lippincott Williams & Wilkins, Inc.