Some patients may not attain relief of nocturnal gastric acidity with the use of proton pump inhibitors alone and may need an additional evening antisecretory medication.

In the present study, conducted by Robinson et al, 16 subjects with chronic heartburn were subjected to 24-hr gastric and esophageal pH measurement at baseline and after six days of treatment with a proton pump inhibitor (PPI) alone at 08:00 hr followed by placebo, ranitidine, or PPI at 22:00 hr.

Integrated acidity was calculated from cumulative, time-weighted mean acid levels (obtained from pH values for each second).

• Baseline integrated gastric acidity was found to increase over 24 hr, while integrated esophageal acidity increased only till 22:00 hr.
• Morning PPI almost eliminated 24-hr esophageal acidity and led to a significant reduction in overall gastric acidity; however, it did not do away with nocturnal gastric acidity.
• Addition of evening dose of ranitidine or PPI nearly abolished nocturnal rise in gastric acidity.
• Integrated acidity appeared to be more sensitive than time pH < 4 to evaluate gastric and esophageal acidity and their inhibition with the drugs.

Addition of low-dose ranitidine can help in controlling nocturnal gastric acidity which can occur with conventional PPI treatment regimen.

Source: Robinson M, Rodriguez-Stanley S, Ciociola AA, et al. Control of Nocturnal Gastric Acidity: A Role for Low Dose Bedtime Ranitidine to Supplement Daily Omeprazole. Digestive Diseases and Sciences 2002;47:265–273.