Addition of a H2 receptor antagonist to PPI improves acid control and decreases nocturnal acid breakthrough

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 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 8 5) 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 I 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.