TOPLINE

Among patients with gastroesophageal reflux disease (GERD), higher anxiety levels were significantly associated with a reduced response to proton pump inhibitor (PPI) therapy, with the strongest effect observed in patients without objective evidence of reflux according to the Lyon Consensus 2.0.

METHODOLOGY

• Persistent symptoms despite PPI therapy are common in patients with GERD, and although the Lyon Consensus 2.0 provides an objective diagnostic framework, factors associated with nonresponse to PPIs across GERD phenotypes remain incompletely defined.
• Researchers conducted a retrospective analysis of prospectively collected data of 204 patients (mean age, 50.3 years; 55.9% women) who presented with dominant esophageal symptoms and had completed an 8-week course of acid suppressive therapy within the preceding 6 months; they underwent off-therapy impedance-pH monitoring after at least 7 days of pharmacologic washout.
• Patients were classified according to the Lyon Consensus 2.0 criteria as having conclusive GERD (23%), inconclusive GERD with supportive evidence (17.2%), inconclusive GERD without supportive evidence (18.1%), and no GERD (41.7%).
• Before impedance-pH monitoring, participants underwent anxiety assessment using the 14-item Hamilton Anxiety Rating Scale (HAM-A), which determined symptoms of both psychic and somatic anxiety over the preceding 8 weeks; according to the HAM-A score, anxiety was categorized as mild (≤ 17), moderate (18-24), or severe (≥ 25).
• After completing therapy, patients retrospectively reported the average severity of their symptoms during the full 8-week treatment period; response to PPIs was defined as a reduction of at least 50% in the total symptom score during the therapy course compared with the pretreatment score.

TAKEAWAY

• The rate of response to PPIs progressively declined from 70.2% in patients with conclusive GERD to 53.3% in those with inconclusive GERD with supportive evidence, 31.6% in those with inconclusive GERD without supportive evidence, and 30.8% in those with no GERD (P < .001).
• Nonresponders had higher mean HAM-A scores than responders in the overall cohort (20.9 vs 13.4; P < .001). Each 1-point increase in HAM-A scores was associated with 14% higher odds of nonresponse to PPIs in patients with inconclusive GERD with supportive evidence (odds ratio [OR], 1.14) and with 22% higher odds in those with no GERD (OR, 1.22; P < .05 for both).
• Compared with mild anxiety, moderate anxiety was significantly associated with PPI refractoriness (OR, 6.25), with the strongest association observed among patients with severe anxiety (OR, 13.3; P < .001 for both).
• In the overall cohort, HAM-A scores showed good discrimination for nonresponse to PPIs, with an area under the receiver operating characteristic curve (AUC) of 0.73, and the highest performance was observed in patients with no GERD (AUC, 0.78).

IN PRACTICE

“Patients with high anxiety and lacking objective GERD findings should be informed about limited PPIs efficacy and the potential benefit of adjunctive behavioral or neuromodulator strategies, supporting a shift from escalation of acid suppression toward personalization of therapy,” the authors of the study wrote.

SOURCE

The study was led by Mentore Ribolsi, Campus Bio Medico University of Rome, Rome, Italy. It was published online in Clinical Gastroenterology and Hepatology.

LIMITATIONS

Response to PPIs was assessed based on reduction in symptoms, which relied on subjective reporting and may have reflected placebo effects. The use of an average 8-week symptom score may not have captured temporal fluctuations in symptom severity during treatment. Symptom severity before and during therapy was based on retrospective recall, which may have introduced recall bias.

DISCLOSURES

The authors reported no funding sources and declared having no potential conflicts of interest.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.