Asthma Patients Don't Need PPI Drugs

Acid Reflux Treatment Has Little Impact, Study Says

By Salynn Boyles
WebMD Health News

Reviewed By Louise Chang, MD

April 8, 2009 -- Results from a new, government-funded study should change treatment practices for millions of asthma patients who take acid reflux drugs but have no heartburn symptoms.

The practice of prescribing acid reflux-targeting proton pump inhibitor (PPI) medications to patients whose asthma is not well controlled with treatment has become common in recent years.

But the new study confirms that acid reflux drugs do not improve asthma control in patients with gastroesophageal reflux disease (GERD) who do not have heartburn or other acid reflux symptoms.

An asthma expert with the NIH's National Heart, Lung and Blood Institute (NHLBI) says millions of asthma patients with so-called "silent GERD" may be taking acid reflux drugs for no reason.

The study appears in the April 9 issue of the New England Journal of Medicine.

"This was a solid, credible trial with results that definitely fill a gap in our knowledge about this practice," says Virginia Taggart, MPH, program director for the NHLBI Division of Lung Diseases.

Asthma and Acid Reflux

More than 22 million adults and children in the United States have asthma. Studies have found that between 32% and 84% of people with asthma also have acid reflux disease, but many do not have classic acid reflux symptoms, such as heartburn and regurgitation resulting from the backup of acid into the esophagus.

It has been widely believed that acid reflux might contribute to asthma symptoms such as coughing, wheezing, and shortness of breath, by causing airway constriction.

Although this may still be true in asthma patients with GERD symptoms, the study showed that silent GERD is not a factor in poorly controlled asthma, study co-author Robert A. Wise, MD, of Johns Hopkins School of Medicine tells WebMD.

The study involved 412 adult patients whose asthma was poorly controlled despite treatment with moderate to high doses of corticosteroids.

All of the study participants reported either having no acid reflux symptoms or having a history of GERD with minimal symptoms.

When the researchers tested the patients for GERD by measuring acidity levels in the esophagus, they found that 40% of the patients actually did have acid reflux disease.

The study participants were randomly assigned to either twice-daily treatment with a widely prescribed PPI drug or a placebo for six months in addition to asthma treatment. During this time, they kept diaries to track their asthma symptoms, and they underwent monthly lung function testing.

Patients who took a PPI and those who did not showed no significant difference in asthma symptoms over the course of the six-month study. They also had similar self-reported quality-of-life scores.

Outcomes were similar among subgroups of patients who would be expected to benefit most from PPI treatment, such as those with silent GERD and those with nighttime awakening from asthma symptoms.

Pulmonologist and lead investigator John Mastronarde, MD, of Ohio State University Medical Center, tells WebMD that the findings should have an immediate impact on asthma treatment.

"The practice of prescribing a PPI to patients without heartburn is probably not something that I will do anymore," he says.

Children May Still Benefit

It is not clear how many patients fall into that category, but Mastronarde and Wise say that many millions of adults with asthma in the U.S. may be taking acid reflux drugs for no good reason.

PPIs are also commonly prescribed to children with poorly controlled asthma. A similarly designed, NHLBI-funded trial is now under way to determine if treating silent GERD in children improves their asthma symptoms.

"Kids are not small adults, and it may very well be that treatment (with a PPI) is beneficial," Mastronarde says.

Wise points out that because a child's esophagus is shorter than an adult's, it is easier for stomach fluids to back up into the throat and reach the lungs.

For this reason, children may benefit from acid reflux drugs even though adults do not.

"We don't want children who might be on this treatment to stop it without reason," Wise says.

In addition to the NHLBI, the American Lung Association provided funding support for the study.

SOURCES: Mastronarde, J.G., New England Journal of Medicine, April 9, 2009; vol 360: pp 1487-1499. John G. Mastronarde, MD, clinical associate professor of medicine, Ohio State University Medical College. Virginia Taggart, MPH, program director and project manager, Division of Lung Diseases, National Heart Lung and Blood Institute, NIH. Robert A. Wise, MD, Johns Hopkins Asthma and Allergy Center, Johns Hopkins University, Baltimore.

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