The Evaluation and Treatment of Adults with Gastroesophageal Reflux Disease

,

Applied Evidence

The Evaluation and Treatment of Adults with Gastroesophageal Reflux Disease

J Fam Pract. 2001 January;50(1):57,58,61-63

References

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Numerous other tests have been proposed to evaluate the patient with suspected GERD: manometry, scintigraphy, esophograms (as part of upper gastrointestinal series), and the Bernstein test (a provocative challenge with hydrochloric acid infusion). Data on the accuracy of these tests are limited by the lack of an accepted reference standard, and most have fallen out of favor because of their inconvenience or limited accuracy. None are more helpful than pH monitoring or endoscopy, and they are therefore not recommended.

Treatment

Pharmacologic

Treatments for GERD address the pathophysiology of the disease; they tend to target the removal of precipitating factors, using gravity or medications to improve acid clearance, lower the acidity of gastric contents, or improve the esophageal sphincter tone. Short-term treatment goals are to relieve symptoms and heal esophagitis; long-term goals are to prevent relapses and sequelae, such as esophageal stricture formation or adenocarcinoma.

Recommendations for lifestyle modifications to lessen GERD symptoms are extensive and mostly based on pathophysiologic data. Possible triggers for GERD include obesity, tight clothing, fatty foods, alcohol, tobacco, caffeine, onions, peppermint, and chocolate.^17-21 Because symptoms are typically worse at night, elevating the head of the bed or avoiding postprandial recumbency is recommended.^22,23 Eliminating these factors has been shown to decrease the amount of acid in the distal esophagus or improve the pressure readings on manometry. This is disease-oriented evidence; it does not necessarily translate into reduced symptoms for patients. The only patient-oriented evidence that supports lifestyle modification is a small crossover trial in which subjects had less heartburn and belching following a hamburger meal compared with the same meal with onions on the burger.¹⁸ Despite the lack of high-quality evidence of effectiveness, guidelines recommend lifestyle modification as the first-line therapy or adjunct to additional medication.^24,25 Because these lifestyle changes are not thought to be harmful and may have other possible health benefits it is reasonable to recommend them to patients until better studies are published.

Promotility agents are a possible treatment of GERD because they improve acid clearance from the esophagus. Older agents such as metoclopramide and bethanecol have little data to support their use^26,27 and are further limited by their central nervous system side effects. A meta-analysis of trial data found that cisapride heals esophagitis and decreases symptoms of GERD²⁸ but was taken off the market because of problems with cardiac arrhythmias.

Acid suppression strategies available over-the-counter include antacids, alginates, and H2-blockers (H2Bs). Small, short-term trials have demonstrated mixed results with regard to symptom relief and lessened acid exposure from both antacids and alginates.^29,30 Longer follow-up in cohort studies suggests a modest benefit from antacids.³¹ More than 24 randomized controlled trials (RCTs) have demonstrated the benefits of H2Bs in the treatment of GERD for both healing esophagitis and symptom relief. The number needed to treat (NNT) is 5; that is, for every 5 GERD patients treated with H2Bs instead of placebo, 1 patient benefits.³² H2Bs also prevent the long-term recurrence of symptoms (NNT =15).³³ There is no clear benefit of one H2B agent over another. Proton pump inhibitors (PPIs) are also well supported by meta-analyses of RCTs in the short term (NNT = 2) and long term (NNT = 3) treatment of GERD.³³ As with H2Bs, no clear advantage is found between different PPI medications.

STEPS. Using the STEPS approach (Safety, Tolerability, Efficacy, Price, Simplicity) to compare H2Bs and PPIs is one way to help guide management of GERD. H2Bs are not associated with any serious long-term complications. PPIs are theoretically linked to malignancy through 2 mechanisms: proliferation of endocrine cells leading to endocrine neoplasia and atrophic gastritis caused by chronic acid suppression as a precursor to gastric adenocarcinoma. However, studies have not borne out these concerns.³⁴ Thus, both H2Bs and PPIs seem equally safe. The best measure of tolerability is the pooled dropout rate, which is the number of patients dropping out of a study for any reason. Dropout rates are about the same for H2Bs and PPIs.³⁵ Meta-analyses of trials comparing the efficacy of H2Bs to PPIs in the short- and long-term treatment of GERD consistently favor PPIs.^33,35 Of 100 patients with GERD, approximately 25 will benefit from treatment with an H2B, and 75 to 80 will benefit from treatment with a PPI.³³ An interesting comparison of trials suggests that the therapeutic gain of PPIs is greatest in those patients with more severe GERD.³⁶ Little data exist about the prevention of complications of GERD with acid suppression. However, 1 small trial found a decreased rate of esophageal stricture recurrence at 1 year in patients with reflux esophagitis (NNT =7) treated with 30-mg lansoprazole compared with those treated with 300-mg ranitidine.³⁷ These data seem to suggest that high-risk patients are more apt to benefit from PPIs than H2Bs.