Background: Post-prandial esophageal acid exposure is a key determinant of symptom generation in gastroesophageal reflux disease. When esophageal acid exposure is high, high symptom intensity may mask individual variation in the relationship between acid exposure and perception.
Aims: To compare how suppression of esophageal acid by omeprazole or by ranitidine combined with antacid influences post-meal heartburn severity and to determine whether active treatment unmasks distinct esophageal acid-symptom phenotypes.
Methods: Two clinical studies used standardized meal tests in subjects with gastroesophageal reflux disease. In the omeprazole study, subjects were tested at baseline and after eight days of treatment. In the ranitidine plus antacid study, subjects were tested after placebo and active treatment in a randomized crossover design. Post-prandial esophageal acid concentration and heartburn intensity were measured for three hours (omeprazole) or four and one-half hours (ranitidine plus antacid). Total values were compared by receiver operating characteristic analysis and by quadrant classification of high and low acid-symptom relationships.
Results: Both active treatments significantly reduced esophageal acid and heartburn intensity compared with control. Under control conditions, nearly all subjects exhibited high acid exposure with high symptom severity. Active treatment redistributed subjects across four distinct phenotypes. Discordant distributions (high-low or low-high) were similar in both trials, whereas concordant distributions differed markedly, reflecting distinct pharmacologic effects on esophageal acid-symptom coupling.
Conclusions: Post-prandial suppression of esophageal acid unmasks latent esophageal acid-symptom phenotypes in gastroesophageal reflux disease. Recognition of these patterns may improve the understanding of treatment response variability and guide individualized therapy.
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