Congratulations to Dr Dr.Mir Jawad Zar Khan , ( India's Top Orthopaedic Surgeon & Managing Director of Germanten Hospital Hyderabad) for His Research Article on Ranidine and noctural gastric acid in Musculoskeletal disorders in Prestigious Journal IJCP. https://www.drjawadortho.com/

1. RANITIDINE
in the management of
Nocturnal Acid Breakthrough
Long term EFFICACY & SAFETYof

2. Copyright 2020 IJCP Publications Ltd. All rights reserved. E-mail: editorial@ijcp.com, Website: www.ijcpgroup.com
Ranitidine:APromisingOptioninManagingNocturnalAcidBreakthroughin
Patients with Musculoskeletal Disorders
Introduction
fte circadian rhythm of gastric acid secretion is lowest in the morning, greater in the evening and attains the peak around midnight. Several
studies have shown a decrease in nocturnal gastric pH in patients with gastroesophageal reflux disease (GERD) as well as healthy volunteers
who take a proton pump inhibitor (PPI) twice daily.1
ftis drop in gastric pH, termed as nocturnal acid breakthrough (NAB), is defined as “the
presence of intragastric pH <4 during the overnight period for at least 60 continuous minutes in patients taking a PPI”.2
Weak lower
esophageal sphincter function and poor esophageal motility may underline prolonged esophageal acid exposure at night secondary to NAB. fte
prevalence of NAB in healthy volunteers varies from 35% to 75% while in patients with GERD, it ranges from 67% to 100%. Moreover, it
has been reported that GERD and its complications occur often in various musculoskeletal disorders such as systemic sclerosis. ftus, it is
important to prescribe appropriate treatment directed at control of NAB in this patient population.1
Is there a need for adding histamine H2 receptor antagonist to PPI?
Numerous studies have shown the efficacy of PPIs in reducing acid secretion. However, these agents do not completely eliminate intragastric
acidity which warrants the need for an additional agent.2,3
For this purpose, the investigators have indicated the potential of histamine
H2
receptor antagonists (H2
RAs). ftese drugs help by targeting night time histamine surge.2
One such H2RA that is considered a potent
option is ranitidine.2,3
Effectiveness of bedtime ranitidine along with twice daily omeprazole therapy (PPI)
A study conducted by Peghini and co-workers evaluated the effect of a dose of ranitidine with a third dose of omeprazole at bedtime on
residual nocturnal acid secretion inpatients who received omeprazole twice daily. fte study involved 12 volunteers who underwent overnight
intragastric pH monitoring after 7 days of treatment with omeprazole 20 mg twice daily, followed by different treatment agents at bedtime.
ftese agents were either placebo or additional omeprazole 20 mg or ranitidine 150 mg or ranitidine 300 mg. fte findings revealed that
additional omeprazole at bedtime reduced the percentage of time with intragastric pH of <4 from 48% to 31% (P <0.005) compared to
omeprazole twice daily with placebo at bedtime. However, ranitidine at bedtime was more effective at reducing this parameter (5%with
150 mg and 6% with 300 mg; P <0.01 versus omeprazole twice daily and at bedtime). Out of 12 volunteers, acid breakthrough was
reported in 11 volunteers who took placebo at bedtime, in 7 who were administered omeprazole, in 4 who were given ranitidine 150 mg,
and in 3 volunteers who were treated with ranitidine 300 mg at bedtime.2
fte acid breakthrough that occurred in more than 90% of volunteers who received PPI twice daily and in more than 50% who received PPI
twice daily and at bedtime suggests that proton pumps were not completely inhibited at even larger doses of PPI. As a consequence, histamine
or acetylcholine may have activated the parietal cell. PPIs inhibit only actively secreting pumps in the secretory canaliculi, sparing those at rest
in the tubulovesicles. On the contrary, the action of H2
RA like ranitidine does not depend on food intake. ftus, it was rapidly absorbed and
absorption was not influenced by food ingestion. fte researchers thus suggested that use of bedtime ranitidine 300 mg along with omeprazole
twice a day is an effective therapeutic approach for managing NAB.2
Given the efficacy of this regime in individuals with NAB, it can be
suggested that it may be a valuable option for managing NAB in patients with GERD, a common symptom of musculoskeletal diseases.
References
1. Janiak P,ftumshirn M, Menne D, et al. Clinical trial: the effects of adding ranitidine at night to twice daily omeprazole therapy on nocturnal acid breakthrough
and acid reflux in patients with systemic sclerosis--a randomized controlled, cross-over trial. Aliment Pharmacol fter. 2007 Nov 1;26(9):1259-65.
2. Tutuian R, Castell DO. Nocturnal acid breakthrough - approach to management. Med Gen Med. 2004;6(4):11.
3. PeghiniPL, Katz PO, Castell DO. Ranitidine controls nocturnal gastric acid breakthroughon omeprazole: a controlledstudy in normalsubjects. Gastroenterology.
1998 Dec;115(6):1335-9.
Dr Mir Jawad Zar Khan
MBBS, MS (Orthopedics), MCh(Ortho)
Fellowship in Arthoplasty (Germany)
Managing Director, Germanten Hospitals,
Telangana
Consultant Orthopedic Surgeon, Specialist in
Trauma, Joint Replacement,
Spine Surgery, Sports Medicine & Pediatric
Orthopedics
ORTHO