Review article: rethinking the “ladder” approach to reflux‐like symptom management in the era of PPI “resistance” ‐ a multidisciplinary perspective

Abstract

Summary Background Despite widespread adoption of potent acid suppression treatment with proton pump inhibitors (PPI) for reflux‐like symptoms, persistent symptoms are commonly reported in primary care and community studies. Aims This multidisciplinary review critically evaluates how the management of reflux‐like symptoms could better reflect their multifactorial pathophysiology. Methods A panel of experts (from general practice, gastroenterology and gastropsychology) attended a series of workshops to review current management and propose a framework for the provision of more individualised care. Results It was agreed that the perceptual (as well as the physiological) causes of reflux‐like symptoms should be considered at the start of management, not as a last resort when all else has failed. A short course of PPI is a pragmatic approach to address reflux‐like symptoms, but equally important is counselling about the gut‐brain axis and provision of symptom‐specific behavioural interventions for those who show signs of somatisation, hypervigilance or co‐existing disorders of gut‐brain interaction. Other low‐harm interventions such as lifestyle and dietary advice, should also be better integrated into care at an early stage. Multidisciplinary care management programmes (including dietary, weight loss, exercise and behavioural intervention) should be developed to promote greater self‐management and take advantage of the general shift toward the use of remotely accessed health care resources. Conclusions Management of reflux‐like symptoms should be adapted to reflect the advances in knowledge about the multifactorial aetiology of these symptoms, addressing both acid‐related and behavioural components early in management. The time has come to treat the patient, not the “disease”.

Patient journey in erosive oesophagitis: real-world perspectives from US physicians and patients

“…21 26 In addition to pharmacological approaches, multidisciplinary care management programmes including dietary, weight loss, exercise and behavioural interventions, are valuable and are being increasingly used in the management of EE. 27 This study provides real-world evidence from all aspects of a patient's journey to assess current practices and outcomes from current clinical practice in the USA. The population enrolled in this study consisted predominantly of patients with LA Grade A (81%) and Grade B EE (14%).…”

“…The more recent availability of new P-CABs, including keverprazan24 and tegoprazan,25 has allowed standard treatment for acid-related conditions to evolve and improve 21 26. In addition to pharmacological approaches, multidisciplinary care management programmes including dietary, weight loss, exercise and behavioural interventions, are valuable and are being increasingly used in the management of EE 27…”

“… 21 26 In addition to pharmacological approaches, multidisciplinary care management programmes including dietary, weight loss, exercise and behavioural interventions, are valuable and are being increasingly used in the management of EE. 27 …”

Optimising reflux symptom burden and patient compliance during PPI washout periods for oesophageal pH monitoring studies: should we be more proactive with alginate use?

“…There is now a positive move away from the dated ‘ladder-based approach’ to escalating reflux treatment in patients with refractory symptoms to a more considered, holistic, biopsychosocial approach, considering a multidimensional clinical profile including results from oesophageal reflux studies. 4 In this context, oesophageal pH/impedance testing has informed the Rome IV diagnostic classification for patients with non-acid-driven symptoms. 5 This has led to the separation of those with truly PPI refractory reflux, PPI dependent reflux and pathological reflux from those with non-acid reflux and those with oesophageal reflux hypersensitivity who have normal acid exposure (‘off PPI’) but have a positive symptom correlation to trivial amounts of acid, and those with functional heartburn who have no positive symptom correlation and no evidence of pathological reflux.…”

“…Therefore, an inappropriate on PPI study would be a missed opportunity to differentiate between these subgroups. There is now a positive move away from the dated ‘ladder-based approach’ to escalating reflux treatment in patients with refractory symptoms to a more considered, holistic, biopsychosocial approach, considering a multidimensional clinical profile including results from oesophageal reflux studies 4. In this context, oesophageal pH/impedance testing has informed the Rome IV diagnostic classification for patients with non-acid-driven symptoms 5.…”