Practical guidelines for managing GERD
Heartburn and espphageal ulcerations are two symptoms of GERD.
At a glance
- Treatment should ordinarily be empirical and not contingent on invasive tests like endoscopy.
- Recommendations for lifestyle modification are numerous but for the most part poorly supported by evidence.
- Long-term treatment with a PPI is strongly recommended for patients with esophagitis or a history of the condition.
- Routine endoscopy of patients with long-standing GERD for Barrett's esophagus is not recommended.
In its first evidence-based Medical Position Statement on the management of gastroesophageal reflux disease (GERD), the American Gastroenterological Association Institute makes specific (and in some cases, perhaps, unexpected) recommendations on medication, lifestyle modification, and the use of endoscopy.
“Primary-care providers [PCPs] will be treating the majority of patients, who will have various forms of GERD,” says John M. Inadomi, MD, professor of medicine at University of California, San Francisco, and chair of the Institute's Clinical Practice and Quality Management Committee. “[Those providers] need to know what evidence supports their practice and when to refer.”
At the clinical level, the diagnosis is made on the basis of symptoms and is irreducibly subjective—heartburn or other manifestations that the patient perceives as “troublesome”—and treatment should ordinarily be empirical and not contingent on invasive tests like endoscopy.
According to the Statement, recommendations for lifestyle modification are numerous but for the most part poorly supported by evidence. “The problem…is that there are simply too many recommendations, and each is too narrowly applicable to enforce the whole set on every patient.”
The authors recommend an approach that tailors recommendations to the individual. Weight loss for patients who are obese or overweight is one intervention with “fair evidence” that it improves outcomes. Elevating the head of the bed for patients whose nighttime symptoms remain troublesome despite acid-suppression therapy is another.
Beyond that, interventions might be recommended selectively despite the paucity of data. “If a patient finds that a food, beverage, or activity seems to precipitate heartburn, counseling him or her to eliminate it makes perfect sense,” says Dr. Inadomi. Candidates for elimination include foods like chocolate, alcohol, and fatty meals that may promote reflux; acidic foods (e.g., citrus fruits and carbonated drinks) associated with heartburn; and behaviors like smoking or retiring within two to three hours of the evening meal that appear to increase acid exposure.
The Statement strongly recommends antisecretory drugs for treatment of GERD and notes that among them, proton-pump inhibitors (PPIs) are more effective than histamine2-receptor antagonists (H2RAs). “PPIs are generally the drugs of first choice,” Dr. Inadomi says.
Side effects with the PPI (most commonly headache, diarrhea, constipation, and abdominal pain) may necessitate trials of various drugs or dosage reduction. When symptoms are intermittent and the patient intends to use medication on an as-needed basis, the more rapidly acting H2RAs, perhaps in combination with an antacid, may be appropriate.
Few data are available to guide clinicians in treating symptoms that remain troublesome despite standard once-daily dosing of a PPI—a not uncommon scenario. Evidence for the most often used approach, b.i.d. dosing, is scarce, although “the pharmacodynamics of the drugs logically support twice-daily dosing” and expert opinion is “essentially unanimous” in its favor, the authors say. (Optimum timing when breakthrough symptoms occur toward the end of the day or overnight is 30-60 minutes before breakfast and dinner).
The common strategy of adding a bedtime dose of an H2RA for “nocturnal acid breakthrough” has no apparent clinical benefit, however. Inadequate response to a twice-daily PPI should be considered treatment failure and an indication that something beyond empirical therapy is needed, according to the Statement.
Citing the lack of data supporting its benefit and concern about associated risks, the authors recommend against metoclopramide as monotherapy or adjunctive therapy in GERD.
The Statement strongly recommends long-term treatment with a PPI for patients with esophagitis or a history of the condition. The dose should be titrated down to the lowest effective level, but discontinuation or an on-demand approach carries a high risk of recurrence; so does switching to an H2RA.
Patients without a history of esophagitis (or with uninvestigated GERD) apparently do well taking medication p.r.n. once symptoms are controlled, and the Statement calls on-demand regimens a reasonable maintenance strategy. “Patients do it anyway, and empirically it works,” Dr. Inadomi says.
The authors note, more broadly, that residual symptoms or intermittent esophageal erosions are not apparently harmful and that maintenance therapy decisions should be based on the impact symptoms are having on the patient's quality of life.