Chest
Volume 116, Issue 5, November 1999, Pages 1257-1264
Journal home page for Chest

Clinical Investigations
ESOPHAGUS
Gastroesophageal Reflux in Asthmatics: A Double-Blind, Placebo-Controlled Crossover Study With Omeprazole

https://doi.org/10.1378/chest.116.5.1257Get rights and content

Study objectives

To investigate the prevalence of gastroesophageal reflux (GER) among patients with asthma and to determine the effect of omeprazole on the outcome of asthma in patients with GER.

Design

A double-blind, placebo-controlled crossover study.

Setting

Asthmatic patients who attended the pulmonary outpatient clinic of Turku University Central Hospital, Finland.

Patients

One hundred seven asthmatic patients.

Interventions

The patients who were found to have GER in ambulatory esophageal pH monitoring were randomized to receive either omeprazole, 40 mg qd, or placebo for 8 weeks. After a 2-week washout period, the patients were crossed over to the other treatment. Spirometry was performed at baseline and immediately after both treatment periods. Peak expiratory values, use of sympathomimetics, and pulmonary and gastric symptoms were recorded daily in a diary.

Results

Pathologic GER was found in 53% of the asthmatic patients. One third of these patients had no typical reflux symptoms. Daytime pulmonary symptoms did not improve significantly (p = 0.14), but a reduction in nighttime asthma symptoms (p = 0.04) was found during omeprazole treatment. In the patients with intrinsic asthma, there was an improvement in FEV1 values (p = 0.049). Based on symptom scores, 35% of the patients were regarded as responders to 8-week omeprazole treatment. The reflux (time [percent] of pH < 4) was found to be more severe (p = 0.002) in the responders.

Conclusions

There is a high prevalence of GER in the asthmatic population. This reflux is often clinically “silent.” After an 8-week omeprazole treatment, there was a reduction in nocturnal asthma symptoms, whereas daytime asthma outcome did not improve. There seems to be a subgroup of asthma patients who benefit from excessive antireflux therapy.

Section snippets

Patients

In order to get as heterogeneous a group of asthmatic patients as possible, the only inclusion criteria was a diagnosis of asthma, which was made according to the guidelines defined by the American Thoracic Society.24 The patients were considered to have asthma if they had reversible bronchial obstruction, documented by a 15% increase in FEV1 after sympathomimetic inhalation, or a 20% decrease in FEV1 after methacholine challenge, or ≥ 20% diurnal variation in peak expiratory flow (PEF) values.

Results

Fifty-seven of 107 asthma patients (53%) were found to have pathologic GER in the ambulatory esophageal pH recording and were randomized. A comparison of the patients who had GER with those patients who did not have GER is shown in Table 1. Of the 57 patients with GER, 20 patients (35%) had no typical reflux symptoms.

Fifty-two patients completed both treatment periods. Three patients dropped out while receiving placebo treatment (two because of intense gastric symptoms), and two dropped out

Discussion

We found a high prevalence (53%) of GER in the asthmatic population. This is in accordance with previous studies, which have shown GER in 32 to 80% of asthmatic patients.1, 2 It is of interest that 35% of the patients who had GER in pH monitoring were free of typical reflux symptoms. Irwin et al31 have similarly shown GER to be clinically “silent” in 24% of asthmatic patients.

Although theophylline has been shown to reduce the pressure of the LES and thus potentially promote GER,32 it has been

References (37)

  • TR Levin et al.

    Omeprazole improves peak expiratory flow rate and quality of life in asthmatics with gastroesophageal reflux

    Am J Gastroenterol

    (1998)
  • M Perrin-Fayolle et al.

    Long-term results of surgical treatment for gastroesophageal reflux in asthmatic patients

    Chest

    (1989)
  • OL Gastal et al.

    Frequency and site of gastroesophageal reflux in patients with chest symptoms: studies using proximal and distal pH monitoring

    Chest

    (1994)
  • D Vincent et al.

    Gastro-oesophageal reflux prevalence and relationship with bronchial reactivity in asthma

    Eur Respir J

    (1997)
  • PW Holmes et al.

    Changes of lung volumes and lung mechanics in asthma and normal subjects

    Thorax

    (1978)
  • CIA Jack et al.

    Simultaneous tracheal and oesophageal pH measurements in asthmatic patients with gastro-oesophageal reflux

    Thorax

    (1995)
  • LE Mansfield et al.

    The role of the vagus nerve in airway narrowing caused by intraesophageal hydrochloric acid provocation and esophageal distention

    Ann Allergy

    (1981)
  • RJR Goodall et al.

    Relationship between asthma and gastro-oesophageal reflux

    Thorax

    (1981)
  • Cited by (207)

    • Proton Pump Inhibitors in Allergy: Benefits and Risks

      2022, Journal of Allergy and Clinical Immunology: In Practice
    • Asthma and Three Colinear Comorbidities: Obesity, OSA, and GERD

      2021, Journal of Allergy and Clinical Immunology: In Practice
    • Treatment of GERD in asthma

      2021, Revue des Maladies Respiratoires
    • Guidelines for the management of asthma in adults: Evidence and recommendations

      2022, Asian Pacific Journal of Allergy and Immunology
    View all citing articles on Scopus

    For editorial comment see page 1150.

    This study was supported by the Finnish Anti-Tuberculosis Association Foundation, the Va¨ino¨ and Laina Kivi Foundation, and the Research Foundation of Respiratory Diseases.

    View full text