Healing erosive esophagitis with a proton pump inhibitor: the more the merrier?

Patients with erosive esophagitis (EE) account for 30% of patients with gastroesophageal reflux disease; only a minority of these patients fail to achieve healing on treatment with a proton pump inhibitor (PPI), once-daily, for 8 weeks. For those patients with EE who have failed to heal on a PPI, given once-daily, current practice is to double the PPI dose although there is little published evidence to support this. In this issue of the American Journal of Gastroenterology, authors from Japan have demonstrated that double-dose PPI produced higher healing rates when given as a split, twice-daily dose than as a once-daily dose for patients with EE who had failed initial therapy with rabeprazole 10 mg once-daily. Quadruple-dose PPI, given as a split dose, did not increase the healing rates but did produce better symptom control, albeit limited, compared with double-dose PPI, given twice-daily. Because subjects, initially, received a lower PPI dose than that generally indicated for EE (rabeprazole 20 mg daily), this study does not provide the eagerly awaited justification for double-dose PPI therapy in patients with EE who have failed standard-dose PPI once-daily. However, it does demonstrate the clinical advantage of a split-dose regimen (AM and PM), compared with a once-daily regimen, when doubling the dose of a PPI for patients with residual EE after initial therapy.