Gastroesophageal Reflux Disease [2007 update]

Purpose, Audience, Authors, and Acknowledgements

Gastroesophageal reflux disease (GERD) is a common chronic, relapsing condition that carries a risk of significant morbidity and possible mortality from resultant complications.  The lack of a gold standard in the diagnosis of GERD presents a clinical dilemma in treating patients with reflux symptomatology.  This CME activity provides clinicians a cost-effective and evidence-based strategy in the diagnosis and treatment of GERD reflux disease. The educational material provides useful summaries on practical aspects of care, including an algorithm for steps in diagnosis and treatment, atypical and warning signs, and information on pharmacologic therapy. 

New in this update are several aspects of treatment and evaluation:

Treatment

• A response to a short course of proton-pump inhibitors (PPIs) is commonly considered to support a diagnosis of GERD.
• Several studies have demonstrated that on-demand therapy with PPIs is the most cost-effective method for GERD treatment.  Generic omeprazole is currently the least expensive PPI.
• Aggressive acid reduction using PPIs bid before meals for at least 2-3 months is now considered the standard treatment for atypical GERD and may be the best way to demonstrate a causal relationship between GERD and extraesophageal symptoms.
• Evidence is insufficient to conclude that PPI treatment benefits cough associated with GERD in adults.
• Endoscopic treatments including thermal ablation, photodynamic therapy and endoscopic mucosal resection offer promise to the patient who is not an operative candidate. These modalities are less invasive and have fewer complications than antireflux surgery, but are also likely to have lower response rates and have not been shown to reduce acid exposure.

Evaluation

• Recent advances in “wireless” pH radiotelemetry capsule technology eliminates the need for the uncomfortable nasoesophageal tube, and increases diagnostic yield by allowing for longer monitoring (e.g., now 48-hour and soon 96-hour).
• Intraluminal impedance monitoring can detect “nonacid” (i.e. liquid/gas) reflux.  This may be important in medically refractory patients with regurgitation who are being considered for surgery or in patients with atypical symptoms.

Key aspects of care include:

• An empiric medication trial without diagnostic testing can identify GERD in most patients.
• Treat with either PPIs or histamine-2 receptor antagonists (H2RAs), with drug selection depending upon clinical efficacy and cost-effectiveness.
• Non-erosive reflux disease (NERD): step-up therapy (H2RA followed by PPI if no improvement) and step-down (PPI followed by the lowest dose of acid suppression) therapy are equally effective for both acute treatment and maintenance therapy.
• Documented erosive esophagitis: Initial PPI therapy is the treatment of choice in acute and maintenance therapy for patients with documented erosive esophagitis
• PPIs should be taken 30–60 minutes before a meal (e.g., QD: breakfast, BID: breakfast & dinner), not at bedtime, to optimize effectiveness.  Increase single dose strength before increasing dosing frequency.
• Warning signs, including non-response to treatment, require diagnostic testing and referral to a GERD specialist.  PPI therapy is treatment of choice in acute and maintenance therapy.

This self-study activity is appropriate for primary care clinicians and other health care providers involved in the diagnosis and treatment of GERD in adults.

Team Leader
	Joel J. Heidelbaugh, MD Family Medicine
Team Members
	Arvin S. Gill, MD Geriatric Medicine R. Van Harrison, PhD Medical Education Timothy T. Nostrant, MD Gastroenterology
Author Disclosures
	Team Member Company Relationship Arvin Gill, MD   (None) Van Harrison, PhD   (None) Joel Heidelbaugh, MD   (None) Timothy Nostrant, MD Astra-Zeneca, Janssen (J & J), Sartoris, Tapp (Takeda), Wyeth) Janssen, Merck, Glaxo Consultant

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