Gastroesophageal Reflux Disease [2012 update]

Description: 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 helps clinicians understand and implement a cost-effective and evidence-based strategy for 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 (2 week) course of a proton-pump inhibitor (PPI) often supports a diagnosis of GERD.
• On-demand therapy with PPIs is the most cost-effective method for GERD treatment, as generic omeprazole is currently the least expensive PPI.
• Aggressive acid reduction using PPIs BID before meals for at least 2-3 months is the standard treatment for atypical GERD and can demonstrate a causal relationship between GERD and extra-esophageal symptoms.
• Evidence is insufficient to conclude that PPI treatment benefits cough associated with GERD in adults.
• Patients should not be left on anti-secretory therapy without symptom re-evaluation to minimize cost and potential adverse events (e.g., Clostridium difficile-associated diarrhea; community acquired pneumonia; osteoporotic fracture; vitamin B12, calcium, and magnesium deficiencies, interactions with clopidogrel).

Evaluation

• Recent advances in "wireless" pH radiotelemetry capsule technology eliminates the need for the uncomfortable nasoesophageal tube for pH probe evaluation, and increases diagnostic yield by allowing for longer monitoring (e.g., 48-hour and 96-hour).
• Intraluminal impedance monitoring can detect "nonacid" (e.g., liquid/gas) reflux, important in 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.
• Erosive esophagitis: PPI therapy is the treatment of choice in acute and maintenance therapy
• PPIs should be taken 30–60 minutes before a meal (e.g., daily: 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.