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Are Proton-Pump Inhibitors Beneficial for Patients with Poorly Controlled Asthma?

For patients with minimal heartburn, probably not

Because acid reflux can cause bronchoconstriction, NIH asthma guidelines state the following: "For patients who have poorly controlled asthma . . . investigation for GERD [gastroesophageal reflux disease] may be warranted even in the absence of suggestive symptoms."

To determine whether treatment of occult acid reflux is worthwhile for asthma patients, 412 adults with inadequately controlled asthma were randomized to receive the proton-pump inhibitor (PPI) esomeprazole (Nexium; 40 mg twice daily) or placebo. Reasoning that patients who have highly symptomatic GERD — with or without asthma — would receive acid-suppressive therapy anyway, researchers excluded patients who required medication for heartburn more than once weekly. On ambulatory pH monitoring, 40% of patients exhibited esophageal reflux.

During 6 months of treatment, clinical outcomes and pulmonary function outcomes were not significantly better in the esomeprazole group than in the placebo group. The subgroup of patients with acid reflux (documented by pH monitoring) also did not benefit from esomeprazole.

Comment: This trial shows that treatment with PPIs is not warranted for asthma patients with mild or no heartburn. The findings undermine the NIH recommendation quoted above; we have no reason to investigate asthma patients for silent reflux if PPI therapy is ineffective. In fact, in another recent study, PPI therapy did not convincingly improve asthma symptoms even among patients with highly symptomatic GERD (JW Gen Med Jun 6 2006).

— Allan S. Brett, MD

Published in Journal Watch General Medicine April 16, 2009

Citation(s):

The American Lung Association Asthma Clinical Research Centers. Efficacy of esomeprazole for treatment of poorly controlled asthma. N Engl J Med 2009 Apr 9; 360:1487.

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• PPI Rx, asthma
  Michael C. Brown, 22 Apr 2009 6:24 PM EST
  To my knowledge, PPI's do not reduce reflux/aspiration. Why would one expect them to alleviate asthma symptoms? I would guess... [more]