Additional bedtime medication for the control of night-time acid reflux from the stomach.

The inhibition of gastric acid secretion is an accepted treatment for diseases related to reflux of acid from the stomach. Some types of antacids, known as proton pump inhibitors (PPI), are considered to be the most effective medical treatment for people patients with acid-related diseases such as peptic ulcer, gastro-oesophageal reflux disease (GERD) and Zollinger-Ellison syndrome, but they may not reduce gastric acid secretion sufficiently to prevent night-time acid reflux symptoms. H2-receptor antagonists (H2RAs) have also been used for the treatment of acid-related diseases for more than a decade and might help to control night-time acid reflux, if taken at bedtime along with a high dose of PPI. The results show that additional bedtime H2RAs can decrease the night-time gastric acid breakthrough, but we believe that additional bedtime H2RAs to PPI should only be used as treatment an intervention in clinical trials until further evidence has been found.

Authors' conclusions: 

We can conclude no implications for practice at this stage. Appropriately designed large-scale randomized controlled trials with long-term follow-up are needed to determine the effects of additional bedtime H2RAs in suppressing nocturnal gastric acid breakthrough.

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Background: 

Nocturnal gastric acid breakthrough (NAB) is defined as intragastric pH<4 for more than one continuous hour overnight. Adding H2-receptor antagonists (H2RAs) at bedtime to high-dose proton pump inhibitors is likely to enhance nocturnal gastric pH control and decrease nocturnal gastric acid breakthrough.

Objectives: 

To assess the effectiveness of additional bedtime H2-receptor antagonists in suppressing nocturnal gastric acid breakthrough and the incidence of adverse effects.

Search strategy: 

We identified eligible trials by searching The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 4, 2008), MEDLINE (1966-August 2008), EMBASE (1980-August 2008) and CINAHL (1982-August 2008). We re-ran the search on CENTRAL (The Cochrane Library Issue 4, 2008), and in MEDLINE, EMBASE and CINAHL in June 2004, July 2005, August 2006 and August 2008.

Selection criteria: 

All randomized controlled trials evaluating H2-receptor antagonists for the control of nocturnal gastric acid breakthrough were eligible for inclusion.

Data collection and analysis: 

Two reviewers have independently selected the trials to be included in the review according to the pre-stated eligibility criteria. Disagreements were resolved by a third reviewer. If the data could not be pooled for meta-analysis, a narrative description was provided.

Main results: 

8 small randomized controlled trials were included for meta-analysis. The results show that additional bedtime H2RAs can decrease the prevalence rate of nocturnal gastric acid breakthrough. The results of the analyses for secondary outcomes show that additional bedtime H2RAs can decrease the percentage of time during which pH is less than 4.0 inside the stomach and promote median intragastric pH.

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