Asthma Management Handbook

Gastro-oesophageal reflux disease and asthma

Recommendations

In adults with asthma, manage reflux symptoms and gastro-oesophageal reflux disease according to current guidelines for reflux disease, but do not advise patients that drug treatments for reflux will improve asthma control.

How this recommendation was developed

Evidence-based recommendation (Grade B)

Based on systematic literature review

Clinical question for literature search:

Does GORD treatment/therapy (H2-receptor antagonists, proton pump inhibitors, anti-reflux surgery, acid suppressive therapy) improve asthma control in people with asthma (adults/children) who have a clinical diagnosis of GORD?

Key evidence considered:

  • Chan et al. 20111
  • Ekstrom et al. 19892
  • Goodall et al. 19813
  • Jiang et al. 20034
  • Nagel et al. 19885
  • Sharma et al. 20076
  • Sontag et al. 20037

For adults with asthma who have uncontrolled gastro-oesophageal reflux disease, offer referral for specialist assessment (including assessment for anti-reflux surgery).

How this recommendation was developed

Evidence-based recommendation (Grade C)

Based on systematic literature review

Clinical question for literature search:

Does GORD treatment/therapy (H2-receptor antagonists, proton pump inhibitors, anti-reflux surgery, acid suppressive therapy) improve asthma control in people with asthma (adults/children) who have a clinical diagnosis of GORD?

Key evidence considered:

  • Sontag et al. 20037

In children and adolescents with asthma, manage reflux symptoms and gastro-oesophageal reflux disease according to current age-appropriate guidelines for reflux disease, but do not advise parents or patients that drug treatments for reflux will improve asthma control.

How this recommendation was developed

Evidence-based recommendation (Grade C)

Based on systematic literature review

Clinical question for literature search:

Does GORD treatment/therapy (H2-receptor antagonists, proton pump inhibitors, anti-reflux surgery, acid suppressive therapy) improve asthma control in people with asthma (adults/children) who have a clinical diagnosis of GORD?

Key evidence considered:

  • Holbrook et al. 20128
  • Khorasani et al. 20089
  • Stordal et al. 200510

Do not use proton pump inhibitors to manage uncontrolled asthma symptoms in children or adults who do not have a diagnosis of gastro-oesophageal reflux disease.

How this recommendation was developed

Based on selected evidence

Based on a limited structured literature review or published systematic review, which identified the following relevant evidence:

  • Chan et al. 20111

More information

Gastro-oesophageal reflux disease links with asthma

The majority of patients with asthma report symptoms of gastro-oesophageal reflux disease or an abnormal result on the 24-hour oesophageal pH test.11 Among children treated in referral clinics, the prevalence of gastro-oesophageal reflux disease is higher among those with asthma than those without asthma,12 but the causal link is unclear.12

Asthma may contribute to gastro-oesophageal reflux disease via changes in intrathoracic pressure or the effects of asthma medicines on the gastro-oesophageal sphincter.11

Gastro-oesophageal reflux disease may contribute to bronchoconstriction through various mechanisms (e.g. vagally mediated reflexes, increased airway hyperresponsiveness, chronic microaspiration of gastric fluid into the airways, or airway neurogenic inflammatory responses).11

Although the presence of gastro-oesophageal reflux disease is generally thought to worsen asthma control, the precise effect of gastro-oesophageal reflux disease on asthma is unclear.11

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Effects of gastro-oesophageal reflux disease treatment on asthma

Adults with gastro-oesophageal reflux disease

In adults with asthma and a diagnosis of gastro-oesophageal reflux disease, treatment with a proton pump inhibitor (esomeprazole, lansoprazole, omeprazole, pantoprazole or rabeprazole) produces a small increase in lung function and improves quality of life.1 There is insufficient evidence from randomised controlled clinical trials to determine whether proton pump inhibitor treatment improves asthma symptoms in patients with gastro-oesophageal reflux disease.1

The combination of a proton pump inhibitor and domperidone may improve lung function and asthma symptoms in adults with asthma and gastro-oesophageal reflux disease.46

Earlier small studies of H2-antagonists (conducted before proton pump inhibitors became the standard first-line medical treatment for gastro-oesophageal reflux disease) reported inconsistent effects of ranitidine and cimetidine on lung function and other asthma outcomes.235 In patients with a history of asthma symptoms related to reflux symptoms, H2-antagonist treatment may reduce night-time symptoms and reliever requirement.2

A small study reported that antireflux surgery was more effective than ranitidine for improving asthma symptoms in adults with asthma and gastro-oesophageal reflux disease.7

Children with gastro-oesophageal reflux disease

Limited evidence from randomised controlled clinical trials suggests that proton pump inhibitor treatment (lansoprazole, omeprazole) does not improve asthma in children with gastro-oesophageal reflux disease.810

Clinical trials have not investigated the effects of reflux treatment on asthma in children aged 5 years and under.

Subclinical gastro-oesophageal reflux disease

Subclinical or undiagnosed gastro-oesophageal reflux disease is sometimes thought to contribute to asthma symptoms or poorly controlled asthma, leading to the hypothesis that reflux treatment may be useful in asthma treatment. However, clinical trial findings do not support this strategy:

  • In adults with asthma but without confirmed gastro-oesophageal reflux disease, proton pump inhibitor treatment achieves a small increase in lung function that is unlikely to be clinically important.1
  • In children with poorly controlled asthma but no symptoms of gastro-oesophageal reflux disease, lansoprazole treatment did not improve asthma symptom or lung function, but was associated with increased adverse events (mainly respiratory infections).8
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References

  1. Chan WW, Chiou E, Obstein KL, et al. The efficacy of proton pump inhibitors for the treatment of asthma in adults: a meta-analysis. Arch Intern Med. 2011; 171: 620-9. Available from: http://archinte.jamanetwork.com/article.aspx?articleid=227086
  2. Ekstrom T, Lindgren BR, Tibbling L. Effects of ranitidine treatment on patients with asthma and a history of gastro-oesophageal reflux: a double blind crossover study. Thorax. 1989; 44: 19-23. Available from: http://www.ncbi.nlm.nih.gov/pubmed/2648642
  3. Goodall RJ, Earis JE, Cooper DN, et al. Relationship between asthma and gastro-oesophageal reflux. Thorax. 1981; 36: 116-21. Available from: http://www.ncbi.nlm.nih.gov/pubmed/7022737
  4. Jiang SP, Liang RY, Zeng ZY, et al. Effects of antireflux treatment on bronchial hyper-responsiveness and lung function in asthmatic patients with gastroesophageal reflux disease. World J Gastroenterol. 2003; 9: 1123-5. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12717871
  5. Nagel RA, Brown P, Perks WH, et al. Ambulatory pH monitoring of gastro-oesophageal reflux in "morning dipper" asthmatics. Bmj. 1988; 297: 1371-3. Available from: http://www.ncbi.nlm.nih.gov/pubmed/3146369
  6. Sharma B, Sharma M, Daga MK, et al. Effect of omeprazole and domperidone on adult asthmatics with gastroesophageal reflux. World J Gastroenterology. 2007; 13: 1706-10. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17461474
  7. Sontag SJ, O'Connell S, Khandelwal S, et al. Asthmatics with gastroesophageal reflux: long term results of a randomized trial of medical and surgical antireflux therapies. Am J Gastroenterology. 2003; 98: 987-99. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12809818
  8. Holbrook JT, Wise RA, Gold BD, et al. Lansoprazole for children with poorly controlled asthma: a randomized controlled trial. JAMA. 2012; 307: 373-81. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22274684
  9. Khorasani EN, Fallahi GH, Mansouri F, Rezaei N. The effect of omeprazole on asthmatic adolescents with gastroesophageal reflux disease. Allergy and asthma proceedings : the official journal of regional and state allergy societies. 2008; 29: 517-520. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18926059
  10. Stordal K, Johannesdottir GB, Bentsen BS, et al. Acid suppression does not change respiratory symptoms in children with asthma and gastro-oesophageal reflux disease. Arch Dis Child. 2005; 90: 956-60. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16113133
  11. Boulet LP. Influence of comorbid conditions on asthma. Eur Respir J. 2009; 33: 897-906. Available from: http://erj.ersjournals.com/content/33/4/897.long
  12. Thakkar K, Boatright RO, Gilger MA, El-Serag HB. Gastroesophageal Reflux and Asthma in Children: A Systematic Review. Pediatrics. 2010; 125: e925-e930. Available from: http://pediatrics.aappublications.org/content/125/4/e925.full