Combination Therapy

Two agents of different therapeutic classes should not be used routinely. Only modest improvements have been shown when a prokinetic agent is combined with a standard dose of an H2RA. Therefore, patients not responding to standard H2RA doses should be switched to a PPI instead of adding a prokinetic agent. Monotherapy with a PPI is not only more effective, but it also improves compliance with once-daily dosing and is ultimately more cost effective.

The addition of an H2RA at bedtime to PPI therapy has been suggested to decrease nocturnal acid breakthrough. While there may be an immediate effect to control symptoms and keep the pH greater than 4, tachyphylaxis may develop within 1 week. If H2RAs are used at night, it maybe preferable to only use them as needed to provide

a "drug holiday" that may lessen the occurrence of tachyphylaxis. Immediate-release omeprazole-sodium bicarbonate has been shown to decrease nocturnal acid exposure compared with pantoprazole administered daily with the evening meal and lansoprazole administered at bedtime. Although more studies are needed, immediate-release omeprazole may offer an effective option for controlling nocturnal acid exposure and symptoms.

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