Nocturnal acid breakthrough: Clinical significance and management

Nocturnal acid breakthrough is seen in more than 70% of Helicobacter pylori-negative patients taking long-term proton pump inhibitors (PPI). It is defined as an intragastric pH of less than 4 for at least 60 consecutive minutes during the overnight period in patients on PPI therapy. It occurs as a result of the recovery of intragastric acidity. Nocturnal acid breakthrough can be clinically significant in patients with complicated gastroesophageal reflux disease, Barrett's esophagus and esophageal motility disorders because of the potential for continued esophageal mucosal injury. To decrease nocturnal acid breakthrough, for patients on once daily PPI, treatment should be stepped up to twice daily. For patients already on twice daily PPI, nocturnal histamine-2 receptor antagonists may be added, but the long-term effectiveness remains debatable as patients may develop tolerance over the course of time. New PPI with a longer half-life may decrease nocturnal acid breakthrough.