Management Options for Patients With GERD and Persistent Symptoms on Proton Pump Inhibitors: Recommendations From an Expert Panel

Yadlapati, Rena; Vaezi, Michael F.; Vela, Marcelo F.; Spechler, Stuart J.; Shaheen, Nicholas J.; Richter, Joel E.; Lacy, Brian E.; Katzka, David A.; Katz, Philip O.; Kahrilas, Peter J.; Gyawali, C. Prakash; Gerson, Lauren B.; Fass, Ronnie; Castell, Donald O.; Craft, Jenna; Hillman, Luke; Pandolfino, John E.

doi:10.1038/s41395-018-0045-4

Cited by 83 publications

(61 citation statements)

References 16 publications

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“…The parameters assessed include presence of hiatal hernia, acid exposure time (AET), and responsiveness to therapy with proton pump inhibitors. Surgical modality can be considered for those with elevated AET (above 6%) and good symptom correlation [18]. However, management is unclear for patients with multiple GERD manifestations like heartburn and cough, where one of the symptoms responds and other does not following therapies targeted against acid control.…”

Section: Discussionmentioning

confidence: 99%

Frequent Sips of the Water for the Management of Gastroesophageal Reflux Induced Refractory Cough: A Case Report and Review of the Literature

Tariq¹,

Makker²,

Ahmed³

et al. 2019

Case Reports in Gastrointestinal Medicine

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Background. Chronic cough is often associated with gastroesophageal reflux disease (GERD). The role of gastroenterologist in the management of the chronic cough is to identify and manage GERD. Ineffective esophageal motility is often associated with GERD induced cough. Chronic cough is often refractory to medical and surgical management despite adequate acid control. Unresponsiveness warrants a thorough pulmonary evaluation. The pathophysiology of refractory cough in these patients is poorly understood, and hence management is often challenging. Case Presentation. A 75-year-old woman from Ghana was evaluated for GERD associated chronic cough. A 48-hour ambulatory pH study revealed acid exposure of 4.9% and high-resolution manometry showed decreased lower esophageal sphincter pressure, an inadequate response to medical and surgical management of GERD. Postfundoplication ambulatory pH testing demonstrated well-controlled acid reflux but her cough still persisted. Repeat manometry showed an ineffective motility disorder (IEM). Taking frequent sips of water eventually resolved her chronic cough. Conclusion. Frequent sips of water can be used in the management of the gastroesophageal reflux and ineffective motility induced cough. It results in increased esophageal clearance of acid, nonacid reflux, and ingested pharyngeal secretions, thus breaking the cycle of cough generated increased intra-abdominal pressure with reflux and more cough.

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Section: Discussionmentioning

confidence: 99%

Frequent Sips of the Water for the Management of Gastroesophageal Reflux Induced Refractory Cough: A Case Report and Review of the Literature

Tariq¹,

Makker²,

Ahmed³

et al. 2019

Case Reports in Gastrointestinal Medicine

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“…One study noted that 42% of PPI non-responders remained on a PPI with no clinical benefit even after showing they had no acid reflux[42]. Up to 50% patients with GERD symptoms do not respond to a double-dose[16,43]. These numbers suggest that many patients are taking PPIs without any clinical benefit.…”

Section: Therapymentioning

confidence: 99%

Management of gastroesophageal reflux disease: Patient and physician communication challenges and shared decision making

Klenzak

Danelisen

Brannan

et al. 2018

WJCC

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Gastroesophageal reflux disease (GERD) is a common upper esophageal condition and typical symptoms can include heartburn and sensation of regurgitation while atypical symptoms include chronic cough, asthma, hoarseness, dyspepsia and nausea. Typically, diagnosis is presumptive given the presence of typical and atypical symptoms and is an indication for empiric therapy. Treatment management can include lifestyle modifications and/or medication therapy with proton pump inhibitor (PPI) class being the preferred and most effective. Complete symptom resolution is not always achieved and long-term PPI therapy can put patients at risk for serious side effects and needless expense. The brain-gut connection and hypervigilance plays an important role in symptom resolution and treatment success, especially in the case of non-PPI responders. Hypervigilance is a combination of increased esophageal sensory sensitivity in combination with exaggerated threat perception surrounding esophageal symptoms. Hypervigilance requires a different approach to GERD managements, where continued PPI therapy and surgery are usually not recommended. Rather, helping physicians and patients understand the brain-gut connection can guide and improve care. Education and reassurance should be the main pillars or treatment. However, it is important not to suggest the symptoms are due to anxiety alone, this often leads to patient dissatisfaction. Patient dissatisfaction with treatment reveals the need for a more patient-centered approach to GERD management and better communication between patients and providers. Shared decision making (SDM) with the incorporation of patient-reported outcomes (PRO) promotes patient adherence and satisfaction. SDM is a joint discussion between clinician and patient in which a mutually shared solution is explored for GERD symptoms. For SDM to work the physician needs to capture patients’ perceptions which may not be obtained in the standard interview. This can be done through the use of PROs which promote a dialogue with patients about their symptoms and treatment priorities in the context of the SDM patient encounter. SDM could potentially help in the management of patient expectations for GERD treatment, ultimately positively impacting their health-related quality of life.

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“…Approximately 40 % of patients have persistent GERD symptoms despite PPI therapy, and there is increasing awareness with regard to the side effects of life-long PPI use [3,4]. While laparoscopic anti-reflux surgery (LARS) remains the gold standard for PPI-refractory GERD [5,6], less invasive anti-reflux interventions are highly desired [7].…”

Section: Introductionmentioning

confidence: 99%

Anti-reflux mucosal ablation (ARMA) as a new treatment for gastroesophageal reflux refractory to proton pump inhibitors: a pilot study

et al. 2020

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Background The incidence of proton pump inhibitor (PPI)-refractory gastroesophageal reflux disease (GERD) has been increasing. While surgical intervention with Laparoscopic Nissen Fundoplication remains the gold standard, less invasive anti-reflux interventions are desired. We have developed a minimally invasive anti-reflux mucosal ablation (ARMA) treatment. Herein, we report its technical details and describe its feasibility, safety, and efficacy in PPI-refractory GERD. Methods We conducted a prospective single-center single-arm interventional trial evaluating the outcome of ARMA in 12 patients with PPI-refractory GERD. GERD-Health Related Quality of Life Questionnaire (GERD-HRQL) evaluation, Frequency Scale for the Symptoms of GERD (FSSG) assessment, and impedance-pH monitoring were performed at baseline and at 2 months post-ARMA. Results A total of 12 patients underwent ARMA with a median follow-up duration of 9 months (range: 6 – 14 months). Median GERD-HRQL score significantly improved from 30.5 to 12 (P = 0.002); median FSSG score significantly improved from 25 to 10.5 (P = 0.002), and median DeMeester score decreased from 33.5 to 2.8 (P = 0.049) at 2 months follow-up. No immediate complications were observed. Conclusion Our pilot study has shown that ARMA, a new endoscopic treatment for PPI-refractory GERD, is simple, safe, and improves GERD-related symptoms and objective acid reflux parameters.

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Management Options for Patients With GERD and Persistent Symptoms on Proton Pump Inhibitors: Recommendations From an Expert Panel

Cited by 83 publications

References 16 publications

Frequent Sips of the Water for the Management of Gastroesophageal Reflux Induced Refractory Cough: A Case Report and Review of the Literature

Frequent Sips of the Water for the Management of Gastroesophageal Reflux Induced Refractory Cough: A Case Report and Review of the Literature

Management of gastroesophageal reflux disease: Patient and physician communication challenges and shared decision making

Anti-reflux mucosal ablation (ARMA) as a new treatment for gastroesophageal reflux refractory to proton pump inhibitors: a pilot study

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