Initial proton pump inhibitor choice and 6-hour heartburn severity in acute reflux exacerbation: a prospective two-centre cohort study

Acute exacerbations of gastro-oesophageal reflux disease commonly bring patients to emergency departments, where rapid symptom control matters more than mucosal healing, yet head-to-head data on symptom severity in the first hours after an oral dose are scarce. In this prospective two-centre cohort study, 189 adults with an acute reflux exacerbation and a Gastroesophageal Reflux Disease Questionnaire score of 8 or more received dexrabeprazole 10 mg, esomeprazole 20 mg or pantoprazole 40 mg, chosen by the treating physician before enrolment. The primary outcome was heartburn visual analogue scale (VAS) score six hours after the first dose, analysed by analysis of covariance adjusted for baseline VAS and nine covariates. The overall adjusted group effect was significant (F(2,171) = 6.32; p = 0.002). Adjusted six-hour VAS was lower with dexrabeprazole than pantoprazole (− 0.83 points, 95% confidence interval − 1.36 to − 0.30) and than esomeprazole (− 0.77, − 1.27 to − 0.27; both Holm-adjusted p = 0.007); comparators showed no detectable difference. In a post hoc exploratory analysis, adjusted probabilities of ≥ 50% heartburn reduction were 68.3%, 31.5% and 33.7%. Treatment was not randomly allocated and the analysis plan followed data collection, so these findings concern prescribing regimens rather than equipotent doses, are hypothesis-generating and require randomised confirmation.