PMID- 34270955 OWN - NLM STAT- MEDLINE DCOM- 20220117 LR - 20220117 IS - 1528-0012 (Electronic) IS - 0016-5085 (Linking) VI - 161 IP - 5 DP - 2021 Nov TI - Value of pH Impedance Monitoring While on Twice-Daily Proton Pump Inhibitor Therapy to Identify Need for Escalation of Reflux Management. PG - 1412-1422 LID - S0016-5085(21)03238-8 [pii] LID - 10.1053/j.gastro.2021.07.004 [doi] AB - BACKGROUND AND AIMS: Acid exposure time (AET) and reflux episode thresholds from the Lyon Consensus may not apply for pH impedance studies performed while on proton pump inhibitor (PPI) therapy. We aimed to determine metrics from "on PPI" pH impedance studies predicting need for escalation of therapy. METHODS: De-identified pH impedance studies performed while on twice-daily PPI (Diversatek, Boulder, CO) in healthy volunteers (n = 66, median age 37.5 years, 43.9% female), and patients with proven gastroesophageal reflux disease (GERD) (European heartburn-predominant cohort: n = 43, median age 57.0 years, 55.8% female; North American regurgitation-predominant cohort: n = 42, median age 41.6 years, 42.9% female) were analyzed. Median values and interquartile ranges for pH impedance metrics in healthy volunteers were compared with proven GERD patients with and without 50% symptom improvement on validated measures. Receiver operating characteristic (ROC) analyses identified optimal thresholds predicting symptom response. RESULTS: Both conventional and novel reflux metrics were similar between PPI responders and nonresponders (P >/= .1 for each) despite differences from healthy volunteers. Combinations of metrics associated with conclusively abnormal reflux burden (AET >4%, >80 reflux episodes) were seen in 32.6% and 40.5% of heartburn and regurgitation-predominant patients, respectively, 57.1% and 82.4% of whom reported nonresponse; and 85% with these metrics improved with invasive GERD management. On ROC analysis, AET threshold of 0.5% modestly predicted nonresponse (sensitivity, 0.62; specificity, 0.51; P = .22), and 40 reflux episodes had better performance characteristics (sensitivity, 0.80; specificity, 0.51; P = .002); 79% with these metrics improved with invasive GERD management. CONCLUSION: Combinations of abnormal "on PPI" pH impedance metrics are associated with PPI nonresponse in proven GERD patients, and can be targeted for treatment escalation, including surgery, particularly in regurgitation-predominant GERD. CI - Copyright (c) 2021 AGA Institute. Published by Elsevier Inc. All rights reserved. FAU - Gyawali, C Prakash AU - Gyawali CP AD - Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri. Electronic address: cprakash@wustl.edu. FAU - Tutuian, Radu AU - Tutuian R AD - Division of Gastroenterology, University Clinics for Visceral Surgery and Medicine, Bern University Hospital, Bern, Switzerland. FAU - Zerbib, Frank AU - Zerbib F AD - Centre Hospitalier Universitaire de Bordeaux, Centre Medico-chirurgical Magellan, Hopital Haut-Leveque, Gastroenterology Department, Universite de Bordeaux, Institut National de la Sante et de la Recherche Medicale CIC 1401, Bordeaux, France. FAU - Rogers, Benjamin D AU - Rogers BD AD - Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri; Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville School of Medicine, Louisville, Kentucky. FAU - Frazzoni, Marzio AU - Frazzoni M AD - Department of Specialized Medicine, Digestive Pathophysiology Unit, Baggiovara Hospital, Modena, Italy. FAU - Roman, Sabine AU - Roman S AD - Digestive Physiology, Hospices Civils de Lyon, Hopital Edouard Herriot, Universite de Lyon, Lyon, France; Laboratory of Therapeutic Applications of Ultrasound, Institut National de la Sante et de la Recherche Medicale U1032, Universite de Lyon, Lyon, France. FAU - Savarino, Edoardo AU - Savarino E AD - Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy. FAU - de Bortoli, Nicola AU - de Bortoli N AD - Gastroenterology Unit, Department of Translational Research and New Technology in Medicine and Surgery. University of Pisa, Pisa, Italy. FAU - Vela, Marcelo F AU - Vela MF AD - Division of Gastroenterology, Mayo Clinic, Scottsdale, Arizona. FAU - Sifrim, Daniel AU - Sifrim D AD - Barts and The London School of Medicine and Dentistry Queen Mary, University of London, London, United Kingdom. LA - eng PT - Journal Article PT - Multicenter Study DEP - 20210714 PL - United States TA - Gastroenterology JT - Gastroenterology JID - 0374630 RN - 0 (Proton Pump Inhibitors) SB - IM MH - Adult MH - Drug Administration Schedule MH - *Drug Monitoring MH - Electric Impedance MH - *Esophageal pH Monitoring MH - Europe MH - Female MH - Gastroesophageal Reflux/diagnosis/*drug therapy/physiopathology MH - Heartburn/diagnosis/*drug therapy/physiopathology MH - Humans MH - Male MH - Middle Aged MH - Predictive Value of Tests MH - Proton Pump Inhibitors/*administration & dosage/adverse effects MH - Retrospective Studies MH - Time Factors MH - Treatment Outcome MH - United States MH - Young Adult OTO - NOTNLM OT - Acid Exposure Time OT - Gastroesophageal Reflux Disease OT - Proton Pump Inhibitor OT - Reflux Episodes OT - pH Impedance Monitoring EDAT- 2021/07/17 06:00 MHDA- 2022/01/18 06:00 CRDT- 2021/07/16 20:15 PHST- 2021/05/19 00:00 [received] PHST- 2021/07/06 00:00 [revised] PHST- 2021/07/07 00:00 [accepted] PHST- 2021/07/17 06:00 [pubmed] PHST- 2022/01/18 06:00 [medline] PHST- 2021/07/16 20:15 [entrez] AID - S0016-5085(21)03238-8 [pii] AID - 10.1053/j.gastro.2021.07.004 [doi] PST - ppublish SO - Gastroenterology. 2021 Nov;161(5):1412-1422. doi: 10.1053/j.gastro.2021.07.004. Epub 2021 Jul 14.