PPI and asthma

Gastro-oesophageal reflux disease (GORD) is the passing of gastric contents through the gastric cardia into the oesophagus:

• can be a normal physiological event that occurs mainly after meals during the day in healthy people
• abnormal acid reflux occurs when there is significant exposure (pH < 4.0) to the distal oesophagus for longer than 1.2 hours (cumulative time > 5%) over a 24-hour period as established by intra-oesophageal pH monitoring
• abnormal acid reflux is commonly associated with upper gastrointestinal (GI) symptoms such as heartburn, dysphagia, regurgitation, and chest pain
• prevalence of GORD in people with asthma is reported to be three times that in the general population
• a temporal association between the two does not conclusively establish that GORD triggers asthma symptoms (1)

GORD treatment and asthma:

• proton pump inhibitor and histamine (receptor type 2) antagonist drugs aim to suppress acid production in the stomach
  • reducing the risks of acid micro-aspiration into the airway and vagally mediated bronchoconstriction
  • proton pump inhibitors are recommended as the initial approach to reflux management, and asthma guidelines recommend that, especially in severe cases, the presence of GORD should be investigated and treatment provided when appropriate to improve management of asthma symptoms (1)
• effects of GORD treatment on the primary outcomes of number of people experiencing one or more exacerbations and hospital utilisation remain uncertain
  • medical treatment for GORD in people with asthma may provide small benefit for a number of secondary outcomes related to asthma management
• data from Wang et al suggest that patients with long-time PPI use have a significantly higher risk of developing asthma when compared with the general population, regardless of gender and age
  • higher risk of developing asthma of patients with long-duration PPI use is identified based on the general population. We recommended H2RA use prior to PPIs in patients who have no underlying peptic ulcers

Reference:

• Kopsaftis Z, Yap HS, Tin KS, Hnin K, Carson-Chahhoud KV. Pharmacological and surgical interventions for the treatment of gastro-oesophageal reflux in adults and children with asthma. Cochrane Database of Systematic Reviews 2021, Issue 5. Art. No.: CD001496. DOI: 10.1002/14651858.CD001496.pub2. Accessed 12 December 2021.
• Wang YT, Tsai MC, Wang YH, Wei JC. Association Between Proton Pump Inhibitors and Asthma: A Population-Based Cohort Study. Front Pharmacol. 2020;11:607. Published 2020 May 8. doi:10.3389/fphar.2020.00607