Use medications first in managing GERD

Medical therapy with antisecretory drugs should be the first-line treatment for gastroesophageal reflux disease, with antireflux surgery offered only to patients whose symptoms are not controlled by medication or who can’t tolerate the drugs, according to the AGA Institute.

Proton pump inhibitors remain the most effective medical therapy, followed by histamine2-receptor agonists, according to the position paper, published October 2008.

“There is ample evidence that, as a drug class, proton pump inhibitors are more effective in these patients than are histamine receptor blockers,” wrote lead author of Northwestern University Chicago.

The document addresses 12 broad issues concerning the diagnosis and management of gastroesophageal reflux disease (ERD), and was developed based on a technical review undertaken.

For each question, the authors performed a comprehensive literature review; the conclusions were rated using the US Preventive Services Task Force evidence grading system. Where sufficient data were not available, the authors relied upon expert opinion for their conclusions.

Although the authors said there is fair evidence that some lifestyle modifications can benefit patients with GERD, they found no strong evidence that such changes should be broadly recommended for all patients. Patients with nighttime symptoms may benefit from elevating the head of their bed, they wrote. Overweight or obese patients should be urged to lose weight, as this may prevent or delay the need for acid suppression.

The authors found strong evidence that antisecretory drugs, especially proton pump inhibitors, improve outcomes, and fair evidence to support twice-daily dosing for some patients. Although essentially all drug trials used once-daily dosing, expert opinion “is essentially unanimous in recommending twice-daily dosing of PPIs improve symptom relief in patients with . . . an unsatisfactory response to once-daily dosing.”

The authors found no evidence that metoclopramide is useful, either as mono- or adjunctive therapy, and recommended against its use because of its substantial side effect profile.

Strong evidence supported a three tiered diagnostic algorithm. Patients with suspected GERD syndrome and troublesome dysphagia should undergo endoscopy with biopsy as an initial evaluation. Those with suspected GERD treated empirically who fail to respond to twice-daily PPIs may benefit from either an endoscopy or esophageal manometry to pursue alternative diagnoses. Ambulatory pH testing, off of PPI therapy, should be done to substantiate a GERD diagnosis for those who have not responded to empirical therapy, and who have had unremarkable endoscopy and manometry.

There was no evidence that endoscopy used as a screening tool for Barrett’s esophagus reduces mortality from esophageal adenocarcinoma in the setting of chronic GERD.

They found strong evidence that antisecretory drugs are also beneficial for patients with suspected extraesophageal reflux symptoms (cough, laryngitis and asthma) when those patients also experience esophageal GERD symptoms.

However, there was no evidence to support the drugs’ use for extrasophageal symptoms in the absence of an accompanying esophageal GERD diagnosis. “The increasing incrimination of GERD as an etiologic factor [in these symptoms] has resulted in widespread overdiagnosis and overtreatment of these conditions.” “Nonetheless, empirical therapy with twice-daily PPIs for 2 months remains a pragmatic clinical strategy for subsets of these patients if they have a concomitant esophageal GERD syndrome. Failing such a trial, etiologies other than GERD should be explored.”

There are no firm data suggesting that GERD is always a progressive disease, going from nonerosive to Barrett’s esophagus. Therefore, routine endoscopy to monitor progression is not recommended. The very limited data available suggested that any risk of progression is very small — less than 2% over 7 years — and endoscopic monitoring has not been shown to lessen the risk of cancer.

Regarding maintenance therapy, they found strong evidence that long-term PPIs are safe and effective, and can be titrated downward in many patients. However, daily therapy will still be necessary for most, as “the likelihood of spontaneous remission of disease is low.”

There was fair evidence supporting long-term, maintenance therapy for patients with extrasophageal reflux symptoms, but only if they have concomitant esophageal GERD syndrome.

They found no significant safety issues with long-term use of antisecretory drugs. “Available data show no worrisome safety signals with PPIs.” “Although there have been concerns about the drugs’ effect on calcium absorption, there is no need for routine bone studies or calcium supplementation, above that which would normally be recommended for patients based on their individual risk factors.

Medical therapy should be the first-line treatment. Surgery may be considered for those who can’t tolerate the drugs, or whose symptoms are not controlled by them. However, the potential benefits of antireflux surgery need to be weighed carefully against the problems it can en-gender. Dysphasia severe enough to require surgical correction occurs in up to 6% of surgical cases, and “both controlled and uncontrolled trials have shown a significant increase bowel symptoms after antireflux surgery.”

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