Treatment of Gastroesophageal Reflux Disease in Adults: An Individualized Approach

Abstract

Until the 1990s, most therapeutic trials in gastroesophageal reflux disease (GERD) focussed upon endoscopic lesions. In fact the correlation between patient symptoms and both the presence and grade of esophagitis is very poor. The classical criteria for the assessment of therapeutic efficacy in GERD have therefore been revised, and there is now a consensus that the relief of symptoms and the long-term control of the disease are the primary aims of therapy for the majority of patients. Proton pump inhibitors (PPIs) represent the mainstay of therapy for patients with non-erosive reflux disease (NERD) as well as esophagitis. Although a stepwise strategy has been recommended in the past, a step-down strategy (starting with a full-dose PPI) appears to be a more cost-effective approach. There are as yet insufficient data to establish the clear superiority of one PPI over others. PPIs have a number of limitations. Symptom relief is significantly inferior in NERD than in erosive esophagitis. The heterogeneity of the NERD group may be one of the most influential factors, but the role of esophageal hypersensitivity has been suggested especially in patients with normal acid exposure. The role of non-acid reflux should also be scrutinized. Long-term control of the disease can be achieved by drug therapy, anti-reflux surgery and now with a variety of endoscopic procedures. The different drug management strategies can be divided into (i) continuous maintenance therapy and (ii) discontinuous therapy which can again be divided into two categories, intermittent and on-demand drug therapy. A case-by-case approach is recommended to determine the personal therapeutic needs and preferences of each individual. Many patients with NERD or mild esophagitis do not require continuous maintenance therapy and recent studies have shown excellent results with different PPI on-demand therapy regimens. Finally when making a choice between different long-term strategies both the clinician and the informed patient have to consider efficacy, safety, tolerability and cost. The potential efficacy of new drugs, especially the GABA(B) agonists and the fast onset acid suppressors, as well as the cost-effectiveness of non-drug strategies (surgery and endoluminal therapies) should be further evaluated.

Gastro-esophageal reflux disease: the recent trend in Japan

“…It is true that PPI is less effective in NERD patients compared with in erosive GERD patients. Like other studies [33,34], our recent study clearly confirmed this observation [24] (Fig. 4).…”

Lifestyle Factors and Efficacy of Lifestyle Interventions in Gastroesophageal Reflux Disease Patients with Functional Dyspepsia: Primary Care Perspectives from the LEGEND Study

“…Kitchin and Castell (16) concluded that, although there were few well-designed, placebo- controlled trials, lifestyle interventions are effective in treating GERD. In contrast, Galmiche et al (17) reported that, while appropriate for promoting general health, many of lifestyle changes are not of benefit in alleviating GERD symptoms. Salyers et al (18) also reported that only 12% of 502 GERD patients received documented counseling regarding lifestyle modifications.…”

Effects of the New Prokinetic Agent DA-9701 Formulated With Corydalis Tuber and Pharbitis Seed in Patients With Minimal Change Esophagitis: A Bicenter, Randomized, Double Blind, Placebo-controlled Study

“…[10][11][12] However, PPIs are less effective in NERD patients than in erosive esophagitis patients. [13][14][15][16] In addition, hiatal hernia is less common and gastric atrophy is more severe in patients with minimal change esophagitis than in those with erosive esophagitis. 13,17 These findings suggest that the characteristics and pathophysiology of minimal change esophagitis differ from those of erosive esophagitis.…”

“…13,17 Moreover, PPIs are less effective in NERD patients than in those with erosive esophagitis patients. [13][14][15][16] These findings suggest that the pathophysiology of minimal change esophagitis may be different from that of erosive esophagitis, and indicate that the development of more effective treatment options is necessary.…”