From the Guidelines
Lifelong proton pump inhibitor (PPI) therapy is recommended for patients with Barrett's esophagus, but the dose should be reviewed regularly to assess for side effects and prevent potential long-term side effects. The primary goal of PPI therapy in these patients is to control symptoms of gastro-oesophageal reflux, rather than to prevent progression to dysplasia and oesophageal cancer 1. According to the most recent guidance from the National Institute for Health and Care Excellence (NICE), there is limited evidence to support the use of high-dose PPIs for chemoprevention in patients with Barrett's esophagus, and the current evidence does not justify a recommendation for high-dose PPIs 1.
Key Considerations
- The standard approach is to use medications such as omeprazole (20-40 mg daily), esomeprazole (20-40 mg daily), pantoprazole (40 mg daily), lansoprazole (30 mg daily), or dexlansoprazole (30-60 mg daily) for symptom control.
- Patients should also implement lifestyle modifications including weight loss if overweight, avoiding meals within 3 hours of bedtime, elevating the head of the bed, and avoiding trigger foods.
- Regular endoscopic surveillance is still necessary regardless of PPI therapy, with frequency determined by the presence and grade of dysplasia.
- The dose of PPIs should be reviewed regularly to assess for side effects and prevent potential long-term side effects such as bone fractures, infections, and electrolyte disturbances 1.
Evidence Summary
The NICE guidance on monitoring and management of Barrett's oesophagus and stage I oesophageal adenocarcinoma recommends that acid-suppressant medication such as PPIs should be offered to all patients to control symptoms of gastro-oesophageal reflux, but the dose should be reviewed regularly to assess for side effects and prevent potential long-term side effects 1. This recommendation is based on the results of two RCTs, including the AspECT trial, which showed that high-dose PPIs had no clinically important effect on outcomes, including all-cause mortality, progression to any grade of dysplasia or cancer, and serious adverse events 1.
From the Research
Proton Pump Inhibitor Use in Barrett's Esophagus
- The use of proton pump inhibitors (PPIs) in patients with Barrett's esophagus is a common practice, particularly during the treatment of dysplasia and early esophageal adenocarcinoma 2.
- High-dose PPI therapy is advised during the treatment of Barrett's esophagus with dysplasia and early esophageal adenocarcinoma 2.
- However, there is no clear recommendation on the long-term use of PPIs in patients with Barrett's esophagus without dysplasia or after successful endoscopic eradication therapy.
Management of Barrett's Esophagus
- The management of Barrett's esophagus involves endoscopic surveillance, endoscopic eradication therapy, and medical therapy with PPIs 3, 2, 4.
- Endoscopic eradication therapy is recommended for patients with high-grade dysplasia and those with low-grade dysplasia 3, 2, 4.
- Surveillance intervals are recommended based on the degree of dysplasia and the presence of other risk factors 3, 4.
Risk Stratification
- Risk stratification of patients with Barrett's esophagus is important to identify those at higher risk of progression to esophageal adenocarcinoma 5.
- Factors associated with higher risk of progression include male sex, multifocality, and nodules, while older age and shorter BE length are associated with regression 5.
- The use of PPIs may be considered as part of the management strategy for patients with Barrett's esophagus, particularly those with dysplasia or at high risk of progression.