Ignite Creation Date:
2024-05-05 @ 7:02 PM
Last Modification Date:
2024-10-26 @ 9:41 AM
Study NCT ID:
NCT00591877
Status:
WITHDRAWN
Last Update Posted:
2012-10-26
First Post:
2007-12-27
Brief Title:
A Study to Evaluate the Role of Alternative Medicine in Difficult to Treat GERD Patients
Sponsor:
Midwest Biomedical Research Foundation
Organization:
Midwest Veterans Biomedical Research Foundation
Study Overview
Official Title:
A Study to Evaluate the Role of Alternative Medicine in Difficult to Treat GERD Patients
Status:
WITHDRAWN
Status Verified Date:
2012-10
Last Known Status:
None
Delayed Posting:
No
If Stopped, Why?:
Unable to enroll elegible subjects No subjects enrolled study closed
Has Expanded Access:
False
If Expanded Access, NCT#:
N/A
Has Expanded Access, NCT# Status:
N/A
Acronym:
None
Brief Summary:
Patients with refractory GERD on BID PPIs assigned to the acupuncture group will have significant improvement in their symptoms after receiving acupuncture for 6 weeks as compared to sham acupuncture given for the same duration
Primary Aim 1To determine the efficacy of acupuncture in the treatment of refractory GERD
Participants with refractory GERD on BID PPIs randomized to yoga will have a significant relief in the symptoms of reflux
Primary Aim 2To determine the efficacy of yoga in the treatment of refractory GERD
Primary Aim 1To determine the efficacy of acupuncture in the treatment of refractory GERD
Participants with refractory GERD on BID PPIs randomized to yoga will have a significant relief in the symptoms of reflux
Primary Aim 2To determine the efficacy of yoga in the treatment of refractory GERD
Detailed Description:
BACKGROUND
Prevalence and burden of disease
Gastroesophageal reflux disease GERD defined as presence of symptoms of heartburn andor acid regurgitation is a common chronic disorder It is a significant health problem especially in the Western population associated with a huge economic burden and impaired quality of life 1 2 The prevalence of GERD in the adult population of the United States is 40 symptoms at least once a month Approximately 20 report GERD related symptoms weekly while 14 report them on a daily basis
The leading gastrointestinal symptoms evaluated in a primary care office setting are those related to a diagnosis of GERD The mainstay of treatment for GERD symptoms at present time are proton pump inhibitors PPI in combination with life style changes In fact PPI have become one of the most commonly written prescriptions trends suggesting that per year scripts have doubled since 1999 It is estimated that Americans spend in excess of 10 billion US dollarsyear on PPIs and two of the top five selling drugs in the United States are PPIs 5 For patients who prefer to refrain from long-term medication use may benefit from acid-reflux surgeries such as Nissen fundoplication However acid-reflux reducing procedures are associated with operative morbidity and mortality including several complications including gas bloat syndrome A large number of patients who undergo surgery for reflux symptoms may eventually relapse and require PPIs Thus treatment of reflux either pharmacological or surgical is costly 6-9 and presents a significant economic burden on the health-care delivery system
Social Impact of the disease
GERD symptoms are associated with bodily pain impaired social emotional and physical functioning which has a profound impact on daily living Much research has been done to evaluate the true burden of GERD on our society For instance 40 of patients with nighttime symptoms of GERD reported that such symptoms affected their ability to function the next day Furthermore 27 of these patients reported that their own night-time symptoms affected their spouses ability to sleep 10 Clearly this data indicates a huge number of Americans who report the effects of heartburn on personal and spousal quality of life GERD symptoms need to be addressed effectively as successful treatment for GERD results in improvements in health related quality of life 11 12 In the treatment of GERD the goal should be complete symptom resolution as this has been shown to be associated with a clinically significant improvement in health related quality of life HRQL 13
Refractory GERD
Despite life style changes and compliant therapy with PPI a large number of patients may have persistent symptoms and classified to have refractory GERD a distinctive group that is difficult to manage 14 The putative reasons remain poorly defined but likely include contributions from factors such as non-acid reflux visceral hypersensitivity and abnormal esophageal motor events 14 A study by Tack et al investigated mechanisms for poor response to PPI therapy and showed persistence of acid reflux in 11 bile reflux alone in 38 and a combination of acid and bile reflux in 26 However persistence of acid or bile reflux does not prove a causal relationship with symptoms 15 Also in this group of individuals with acid or bile reflux on BID PPIs a possible treatment option is Nissens fundoplication the utility of which is yet to be proven in this cohort There is no consensus definition of refractory GERD and generally it is defined as non-response of symptoms to optimum PPI trial The goal of providing symptomatic relief to these refractory patients is extremely challenging in view of limited options It is to these patients that the investigators would like to evaluate in a feasibility study the use of complementary medicine modalities including acupuncture and yoga that may be relatively safe cost-effective therapies to help with the distressing symptoms of GERD
Complementary and alternative medicine
Complementary and alternative medicine CAM is a group of diverse medical and health care systems therapies and products that are not presently considered to be part of conventional medicine These methods have been used for centuries in the eastern culture for a myriad group of diseases CAM became popular in the US in the 1990s where majority of people used it as a complement to conventional medicine and not as an alternative 16-18 Recently there has been much interest in applying these modalities not as secondary therapies to conventional treatment but as the primary method Amongst them acupuncture and yoga have gained a great deal of popularity
Acupuncture AC
Acupuncture is part of the traditional Chinese medicine a complete system of healing that dates back to 200 BC The general theory of acupuncture is based on the premise that there are patterns of energy flow Qi through the body that are essential for health and disruptions of this flow are believed to be responsible for disease Studies have shown that AC modulates the endorphin system via the central pain processing pathways 19 20 Acupuncture has been widely used for various gastrointestinal disorders It is conceivable that acupuncture may be effective in patients with GERD because it has been shown to alter acid secretion GI motility and visceral pain 21 22
The pathogenesis of GERD is multifactorial The predominant mechanism postulated to cause GERD is transient relaxation of the lower esophageal sphincter TLESR Pathological reflux may also occur due to low LES pressures 23 Studies have shown that acupoint stimulation can decrease the rate of TLESRs and hence prevents reflux 24 The investigators propose to use 3 acupoints ST-36 PC-6 CV-12 for treatment of symptoms of GERD These points are described in the subsequent sections Acupuncture will be performed by Dr Santosh Sharma who has the expertise in this treatment modality and is currently offering his therapy for several years at the Veterans Affairs Medical Center Kansas City
Yoga
Yoga refers to a combination of breathing exercises and postures designed to involve specific muscle groups with systemic effects on the various organ systems Yoga originated in India at least 3000 years ago The practice of yoga came to US in 1890 and gained popularity in 1960s because of a rising interest in and cultural acceptance of alternative modalities and mind body therapies Yoga is offered in local YWCA health clubs and yoga centers and in hospitals as part of disease prevention and management programs 25The most popular form is Hatha yoga As discussed below the usefulness of yoga has been studied in certain chronic illnesses such as back pain with promising results The investigators propose to use yoga exercises specifically designed for reflux symptoms Dr Vijay Kumar will be offering yoga classes to patients with refractory GERD Dr Vijay Kumar is a Professor of Computer Science at University of Missouri - Kansas City and has been offering classes for several years at various levels
Evidence for use of acupuncture and yoga
Several randomized controlled trials have been conducted demonstrating the beneficial effects of acupuncture A randomized controlled study in 29 patients with mild to moderate ulcerative colitis with a 4 month follow up after completion of acupuncture sessions showed a statistically significant improvement in colitis activity index CAI as compared to the control group The study concluded that acupuncture provided an additional therapeutic benefit to patients with mild to moderate ulcerative colitis 26
Another randomized 3-arm study was conducted to assess the efficacy and safety of traditional Chinese acupuncture compared with sham acupuncture needling at defined non-acupuncture points and conservative therapy in patients with chronic pain due to osteoarthritis of the knee Addition of acupuncture led to significant improvement in the symptoms 27 Recently Dickman et al evaluated the efficacy of adding acupuncture twice a week over 4 weeks as compared to doubling the PPI dose in 30 refractory GERD patients28 The acupuncture group demonstrated a significant decrease in mean daytime heartburn scores compared to high-dose PPI group Mean nighttime heartburn and regurgitation scores improved only in the acupuncture group Thus this study showed that adding acupuncture as compared to doubling the PPI dose was more effective in controlling symptoms of GERD in patients on standard dose of PPI
Similar benefits have been demonstrated with the use of yoga A randomized controlled trial compared yoga exercise and self care book for chronic low back pain showed that yoga was more effective than a self-care book for improving function and reducing chronic low back pain and the benefits persisted for at least several months 29 Yoga was also found to be useful in improving symptoms related to irritable bowel in a randomized trial conducted in Canada 30
CLINICAL RELEVANCE OF THIS STUDY GERD is a well known widely prevalent clinical entity The symptoms of GERD if not relieved can affect the daily functioningproductivity of individuals This can be especially frustrating for some patients who may spend hundreds of dollars every year on prescription medications and are still not able to obtain relief of their symptoms In the United States alone it is estimated that PPI costs alone make up over 10billionyear 5 However despite these staggering costs it is clear that even PPI therapy is not the definitive answer for all patients Indeed it has been reported that 37 of patients receiving PPIs also note concomitant antacid use This finding underscores the fact that even with PPI therapy a large percentage of patients do not achieve full symptom relief When left untreated--or when treated inadequately--severe GERD can progress to esophagitis esophageal ulcers esophageal strictures laryngeal disease chronic cough Barretts esophagus and esophageal adenocarcinoma Clearly such patients with refractory symptoms are the ones in the direst need for additional modalities of therapy Yoga and acupuncture may be a promising option for these patients as they represent cost-effective yet underused options which may be usefully employed to control the symptoms of GERD
Data Collection
Patient demographics order of randomization responses to questionnaires and antacid use will be collected by the study coordinator and recorded in a database
RISK AND BENEFIT TO THE STUDY PARTICIPANT
This pilot prospective study has the potential to identify new treatments for GERD symptoms The participants in this study may experience relief from their GERD symptoms persistent on high dose acid suppressive therapy This may improve their quality of life and level of functioning The risks to the study group are minimal There is minor risk of bruising needle breakage and infection with the acupuncture needles and musculoskeletal symptoms in patients undergoing yoga If the study shows significant improvement in reflux symptoms with acupuncture or yoga then these methods may have a wider application to the entire spectrum of GERD symptoms with the prospect of avoiding pharmacologic and surgical therapies
STATISTICAL METHODS AND DATA ANALYSIS
Data Analysis
Data will be analyzed with the help of a statistical software program Categorical and continuous variables will be compared using the Students t-test and chi-square test A p value of 005 will be considered significant
Prevalence and burden of disease
Gastroesophageal reflux disease GERD defined as presence of symptoms of heartburn andor acid regurgitation is a common chronic disorder It is a significant health problem especially in the Western population associated with a huge economic burden and impaired quality of life 1 2 The prevalence of GERD in the adult population of the United States is 40 symptoms at least once a month Approximately 20 report GERD related symptoms weekly while 14 report them on a daily basis
The leading gastrointestinal symptoms evaluated in a primary care office setting are those related to a diagnosis of GERD The mainstay of treatment for GERD symptoms at present time are proton pump inhibitors PPI in combination with life style changes In fact PPI have become one of the most commonly written prescriptions trends suggesting that per year scripts have doubled since 1999 It is estimated that Americans spend in excess of 10 billion US dollarsyear on PPIs and two of the top five selling drugs in the United States are PPIs 5 For patients who prefer to refrain from long-term medication use may benefit from acid-reflux surgeries such as Nissen fundoplication However acid-reflux reducing procedures are associated with operative morbidity and mortality including several complications including gas bloat syndrome A large number of patients who undergo surgery for reflux symptoms may eventually relapse and require PPIs Thus treatment of reflux either pharmacological or surgical is costly 6-9 and presents a significant economic burden on the health-care delivery system
Social Impact of the disease
GERD symptoms are associated with bodily pain impaired social emotional and physical functioning which has a profound impact on daily living Much research has been done to evaluate the true burden of GERD on our society For instance 40 of patients with nighttime symptoms of GERD reported that such symptoms affected their ability to function the next day Furthermore 27 of these patients reported that their own night-time symptoms affected their spouses ability to sleep 10 Clearly this data indicates a huge number of Americans who report the effects of heartburn on personal and spousal quality of life GERD symptoms need to be addressed effectively as successful treatment for GERD results in improvements in health related quality of life 11 12 In the treatment of GERD the goal should be complete symptom resolution as this has been shown to be associated with a clinically significant improvement in health related quality of life HRQL 13
Refractory GERD
Despite life style changes and compliant therapy with PPI a large number of patients may have persistent symptoms and classified to have refractory GERD a distinctive group that is difficult to manage 14 The putative reasons remain poorly defined but likely include contributions from factors such as non-acid reflux visceral hypersensitivity and abnormal esophageal motor events 14 A study by Tack et al investigated mechanisms for poor response to PPI therapy and showed persistence of acid reflux in 11 bile reflux alone in 38 and a combination of acid and bile reflux in 26 However persistence of acid or bile reflux does not prove a causal relationship with symptoms 15 Also in this group of individuals with acid or bile reflux on BID PPIs a possible treatment option is Nissens fundoplication the utility of which is yet to be proven in this cohort There is no consensus definition of refractory GERD and generally it is defined as non-response of symptoms to optimum PPI trial The goal of providing symptomatic relief to these refractory patients is extremely challenging in view of limited options It is to these patients that the investigators would like to evaluate in a feasibility study the use of complementary medicine modalities including acupuncture and yoga that may be relatively safe cost-effective therapies to help with the distressing symptoms of GERD
Complementary and alternative medicine
Complementary and alternative medicine CAM is a group of diverse medical and health care systems therapies and products that are not presently considered to be part of conventional medicine These methods have been used for centuries in the eastern culture for a myriad group of diseases CAM became popular in the US in the 1990s where majority of people used it as a complement to conventional medicine and not as an alternative 16-18 Recently there has been much interest in applying these modalities not as secondary therapies to conventional treatment but as the primary method Amongst them acupuncture and yoga have gained a great deal of popularity
Acupuncture AC
Acupuncture is part of the traditional Chinese medicine a complete system of healing that dates back to 200 BC The general theory of acupuncture is based on the premise that there are patterns of energy flow Qi through the body that are essential for health and disruptions of this flow are believed to be responsible for disease Studies have shown that AC modulates the endorphin system via the central pain processing pathways 19 20 Acupuncture has been widely used for various gastrointestinal disorders It is conceivable that acupuncture may be effective in patients with GERD because it has been shown to alter acid secretion GI motility and visceral pain 21 22
The pathogenesis of GERD is multifactorial The predominant mechanism postulated to cause GERD is transient relaxation of the lower esophageal sphincter TLESR Pathological reflux may also occur due to low LES pressures 23 Studies have shown that acupoint stimulation can decrease the rate of TLESRs and hence prevents reflux 24 The investigators propose to use 3 acupoints ST-36 PC-6 CV-12 for treatment of symptoms of GERD These points are described in the subsequent sections Acupuncture will be performed by Dr Santosh Sharma who has the expertise in this treatment modality and is currently offering his therapy for several years at the Veterans Affairs Medical Center Kansas City
Yoga
Yoga refers to a combination of breathing exercises and postures designed to involve specific muscle groups with systemic effects on the various organ systems Yoga originated in India at least 3000 years ago The practice of yoga came to US in 1890 and gained popularity in 1960s because of a rising interest in and cultural acceptance of alternative modalities and mind body therapies Yoga is offered in local YWCA health clubs and yoga centers and in hospitals as part of disease prevention and management programs 25The most popular form is Hatha yoga As discussed below the usefulness of yoga has been studied in certain chronic illnesses such as back pain with promising results The investigators propose to use yoga exercises specifically designed for reflux symptoms Dr Vijay Kumar will be offering yoga classes to patients with refractory GERD Dr Vijay Kumar is a Professor of Computer Science at University of Missouri - Kansas City and has been offering classes for several years at various levels
Evidence for use of acupuncture and yoga
Several randomized controlled trials have been conducted demonstrating the beneficial effects of acupuncture A randomized controlled study in 29 patients with mild to moderate ulcerative colitis with a 4 month follow up after completion of acupuncture sessions showed a statistically significant improvement in colitis activity index CAI as compared to the control group The study concluded that acupuncture provided an additional therapeutic benefit to patients with mild to moderate ulcerative colitis 26
Another randomized 3-arm study was conducted to assess the efficacy and safety of traditional Chinese acupuncture compared with sham acupuncture needling at defined non-acupuncture points and conservative therapy in patients with chronic pain due to osteoarthritis of the knee Addition of acupuncture led to significant improvement in the symptoms 27 Recently Dickman et al evaluated the efficacy of adding acupuncture twice a week over 4 weeks as compared to doubling the PPI dose in 30 refractory GERD patients28 The acupuncture group demonstrated a significant decrease in mean daytime heartburn scores compared to high-dose PPI group Mean nighttime heartburn and regurgitation scores improved only in the acupuncture group Thus this study showed that adding acupuncture as compared to doubling the PPI dose was more effective in controlling symptoms of GERD in patients on standard dose of PPI
Similar benefits have been demonstrated with the use of yoga A randomized controlled trial compared yoga exercise and self care book for chronic low back pain showed that yoga was more effective than a self-care book for improving function and reducing chronic low back pain and the benefits persisted for at least several months 29 Yoga was also found to be useful in improving symptoms related to irritable bowel in a randomized trial conducted in Canada 30
CLINICAL RELEVANCE OF THIS STUDY GERD is a well known widely prevalent clinical entity The symptoms of GERD if not relieved can affect the daily functioningproductivity of individuals This can be especially frustrating for some patients who may spend hundreds of dollars every year on prescription medications and are still not able to obtain relief of their symptoms In the United States alone it is estimated that PPI costs alone make up over 10billionyear 5 However despite these staggering costs it is clear that even PPI therapy is not the definitive answer for all patients Indeed it has been reported that 37 of patients receiving PPIs also note concomitant antacid use This finding underscores the fact that even with PPI therapy a large percentage of patients do not achieve full symptom relief When left untreated--or when treated inadequately--severe GERD can progress to esophagitis esophageal ulcers esophageal strictures laryngeal disease chronic cough Barretts esophagus and esophageal adenocarcinoma Clearly such patients with refractory symptoms are the ones in the direst need for additional modalities of therapy Yoga and acupuncture may be a promising option for these patients as they represent cost-effective yet underused options which may be usefully employed to control the symptoms of GERD
Data Collection
Patient demographics order of randomization responses to questionnaires and antacid use will be collected by the study coordinator and recorded in a database
RISK AND BENEFIT TO THE STUDY PARTICIPANT
This pilot prospective study has the potential to identify new treatments for GERD symptoms The participants in this study may experience relief from their GERD symptoms persistent on high dose acid suppressive therapy This may improve their quality of life and level of functioning The risks to the study group are minimal There is minor risk of bruising needle breakage and infection with the acupuncture needles and musculoskeletal symptoms in patients undergoing yoga If the study shows significant improvement in reflux symptoms with acupuncture or yoga then these methods may have a wider application to the entire spectrum of GERD symptoms with the prospect of avoiding pharmacologic and surgical therapies
STATISTICAL METHODS AND DATA ANALYSIS
Data Analysis
Data will be analyzed with the help of a statistical software program Categorical and continuous variables will be compared using the Students t-test and chi-square test A p value of 005 will be considered significant
Study Oversight
Has Oversight DMC:
None
Is a FDA Regulated Drug?:
None
Is a FDA Regulated Device?:
None
Is an Unapproved Device?:
None
Is a PPSD?:
None
Is a US Export?:
None
Is an FDA AA801 Violation?:
None