Nocturnal gastroesophageal reflux disease: issues, implications, and management strategies.

The consequences of nocturnal gastroesophageal reflux disease (GERD) may be greater than daytime GERD in terms of clinical complications such as increased risk of esophageal lesions and respiratory conditions, as well as issues of health-related quality of life, sleep, work productivity, and economics. Proton pump inhibitors (PPIs) are the most effective therapy for patients with GERD; however, treatment success is greater in the improvement of daytime symptoms and acid control. Acid suppression of most PPIs, which are administered once daily before breakfast, wanes during the nighttime hours. Although nighttime heartburn improves with once-daily PPI treatment, PPIs are unable to eliminate nighttime heartburn completely. Increasing the dose of a PPI provides longer acid suppression, but the benefits have not been shown to be consistently greater than standard once-daily dosing. Twice-daily dosing, with a dose given before bedtime, would extend the duration of acid suppression into the nighttime hours; however, nocturnal acid breakthrough remains an issue. As a result, improved PPIs that will more reliably control nighttime symptoms and provide on-demand relief have been developed and studied. These newer PPI formulations offer significant hope for the advancement of treatment opportunities.