Perspective: GERD management update

October 20, 2011

BY WILLIAM E. GOLDEN, M.D., AND ROBERT H. HOPKINS, M.D.

Background. Gastroesphageal reflux disease (GERD) is one of the most common conditions affecting adults. One study of an employed population showed a prevalence of about 4%, costing employers more than $3,000 per employee-year over 3 years, more than half of which is due to pharmacy costs. The Agency for Healthcare Research and Quality has recently published a comparative effectiveness review on this topic, which updates their last systematic review from 2005.

Conclusions. Cohort studies suggest that patients with morbid obesity, typical GERD symptoms, and more severe esophagitis have worse treatment outcomes with medical therapy, and that older patients achieve better symptom control with medical treatment.

Medical treatment with proton pump inhibitor (PPI) therapy and antireflux surgery are similarly effective in reducing symptoms and decreasing esophageal exposure to acid. However, the surgical literature is limited by low follow-up rates, with 33%-56% of patients ending up lost to follow-up in long-term studies.

Evidence remains insufficient to assess the effectiveness of the available endoscopic interventions for treatment of GERD compared with other endoscopic techniques, medical therapy, and/or surgery.

There is insufficient evidence to determine whether medical therapy or surgery for GERD is more effective for the prevention of long-term complications, including Barrett’s esophagus and esophageal adenocarcinoma.

There also is insufficient evidence to assess the benefits of treating extraesophageal manifestations (chronic cough, laryngeal symptoms, and asthma) of GERD with surgery or medications. The lack of specificity in attributing these manifestations to GERD makes this issue difficult to study specifically.

Implementation

• Goals of treatment: Usual treatment goals for GERD include improvement of symptoms and quality of life, achieving/maintaining healing of esophageal erosions, and prevention of long-term complications such as Barrett’s esophagus. There is not a consensus approach to achieving these goals.

• Drug therapy: PPIs are more effective than H₂-receptor antagonists for achievement of symptomatic control within 4 weeks and for healing of reflux esophagitis by 8 weeks. Maintenance treatment with PPIs also has been shown to be superior for sustaining symptom control.

Continuous treatment with PPIs is associated with better GERD symptom control and quality of life than is intermittent “on demand” treatment over 6 months with each of the PPI regimens evaluated.

In older patients, daily pantoprazole (40 mg) and rabeprazole (20 mg) have been shown to provide better symptom control and healing of esophagitis compared with over-the-counter omeprazole (20 mg) at 8 weeks. Daily esomeprazole (20 mg) has been shown to result in better endoscopic remission rates than OTC lansoprazole (15 mg) daily for 6 months. It is unclear whether these trial differences reflect clinically significant differences in practice.

Studies have not demonstrated a consistent difference in symptom relief/control or esophagitis healing rates between the following medications and doses: esomeprazole (10-40 mg), lansoprazole (15-30 mg), pantoprazole (20-40 mg), and deslansoprazole (30-90 mg). There is some evidence that rabeprazole (10 mg) may provide better symptom control than esomeprazole (40 mg) at 4 weeks, and that pantoprazole (40 mg) may improve symptoms better than esomeprazole (40 mg) at 24 weeks.

• Role of surgery: There are few to no comparative data on which to base recommendations for any particular antireflux surgical procedure for the treatment of GERD.

For patients with GERD symptoms that are controlled with medical treatment, laparoscopic fundoplication provides symptom control at least equivalent to that provided by continued medical treatment for at least the first year after the procedure, if it is performed by an experienced surgeon at a high-volume center. Ten percent or more of patients treated surgically may require the addition of medical treatment in the long term.

Patients undergoing antireflux surgery in trials were found to have a variety of adverse outcomes, including perioperative infections, incisional hernias, dysphagia, and bloating. The frequency of these events is not predictable by easily identifiable preoperative factors such as patient sex, morbid obesity, degree of esophagitis, presence of hiatal hernias, and/or baseline symptoms. Reoperation rates ranged from 3% to 35% of patients in surgical trials.

• Long-term treatment: Long-term use of PPIs is associated with headache, GI symptoms, increased risk of pneumonia, and infections due to Clostridium difficile and campylobacter. Recent studies have also demonstrated an increased risk of fractures with long-term PPI treatment, although the strength of this association is unclear.

Successful treatment of GERD in patients whose symptoms are poorly controlled with medical treatment remains a challenge. There is limited evidence from two uncontrolled cohort studies of laparoscopic fundoplication demonstrating symptomatic improvement at 5 years.

Despite the large number of medications and interventions available and the numerous clinical trials conducted, GERD remains a significant clinical problem. A number of major questions remain unstudied or, as yet, unanswered.