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Background Gastroesophageal reflux is common among patients with asthma but often causes mild or no symptoms. It is not known whether treatment of gastroesophageal reflux with proton-pump inhibitors in patients who have poorly controlled asthma without symptoms of gastroesophageal reflux can substantially improve asthma control.
Methods In a parallel-group, double-blind trial, we randomly assigned 412 participants with inadequately controlled asthma, despite treatment with inhaled corticosteroids, and with minimal or no symptoms of gastroesophageal reflux to receive either 40 mg of esomeprazole twice a day or matching placebo. Participants were followed for 24 weeks with the use of daily asthma diaries, spirometry performed once every 4 weeks, and questionnaires that asked about asthma symptoms. We used ambulatory pH monitoring to ascertain the presence or absence of gastroesophageal reflux in the participants. The primary outcome was the rate of episodes of poor asthma control, as assessed on the basis of entries in asthma diaries.
Results Episodes of poor asthma control occurred with similar frequency in the placebo and esomeprazole groups (2.3 and 2.5 events per person-year, respectively; P=0.66). There was no treatment effect with respect to individual components of the episodes of poor asthma control or with respect to secondary outcomes, including pulmonary function, airway reactivity, asthma control, symptom scores, nocturnal awakening, or quality of life. The presence of gastroesophageal reflux, which was documented by pH monitoring in 40% of participants with minimal or no symptoms, did not identify a subgroup of patients that benefited from treatment with proton-pump inhibitors. There were fewer serious adverse events among patients receiving esomeprazole than among those receiving placebo (11 vs. 17).
Conclusions Despite a high prevalence of asymptomatic gastroesophageal reflux among patients with poorly controlled asthma, treatment with proton-pump inhibitors does not improve asthma control. Asymptomatic gastroesophageal reflux is not a likely cause of poorly controlled asthma. (ClinicalTrials.gov number, NCT00069823
[ClinicalTrials.gov]
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The members of the writing committee of the American Lung Association Asthma Clinical Research Centers (John G. Mastronarde, M.D., Ohio State University Medical College, Columbus; Nicholas R. Anthonisen, M.D., Faculty of Medicine, University of Manitoba, Winnipeg, Canada; Mario Castro, M.D., Washington University School of Medicine, St. Louis; Janet T. Holbrook, M.P.H., Ph.D., Bloomberg School of Public Health, Johns Hopkins University, Baltimore; Frank T. Leone, M.D., University of Pennsylvania School of Medicine, Philadelphia; W. Gerald Teague, M.D., Emory University School of Medicine, Atlanta; and Robert A. Wise, M.D., Johns Hopkins University School of Medicine, Baltimore) take responsibility for the scientific content and integrity of the article.
Address reprint requests to Dr. Wise at the Johns Hopkins Asthma and Allergy Center, 5501 Hopkins Bayview Cir., Baltimore, MD 21212, or at rwise{at}jhmi.edu.
Related Letters:
Esomeprazole for Asthma
Hsu C.-S., Kao J.-H., Lenglinger J., Riegler M., Wise M. P., Saayman A. G., Frost P. J., Wise R. A., the Writing Committee of the American Lung Association Asthma Clinical Research Centers
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N Engl J Med 2009;
361:206-208, Jul 9, 2009.
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