A recent American Gastroenterological Association Clinical Practice Update for evaluation and management of gastroesophageal reflux disease (GERD) focuses on delivering personalized diagnostic and therapeutic strategies.
The document includes new advice on use of upfront objective testing for isolated extraesophageal symptoms, confirmation of GERD diagnosis prior to long-term GERD therapy even in PPI responders, as well as important elements focused on personalization of therapy.
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Although GERD is common, with an estimated 30% of people in the United States experiencing symptoms, up to half of all individuals on proton pump inhibitor (PPI) therapy report incomplete symptom improvement. That could be due to the heterogeneous nature of symptoms, which may include heartburn and regurgitation, chest pain, and cough or sore throat, among others. Other conditions may produce similar symptoms or could be exacerbated by the presence of GERD.
The authors of the expert review, published in Clinical Gastroenterology and Hepatology, note that these considerations have driven increased interest in personalized approaches to the management of GERD. The practice update includes sections on how to approach GERD symptoms in the clinic, personalized diagnosis related to GERD symptoms, and precision management.
In the initial management, the authors offer advice on involving the patient in creating a care plan, patient education, and conducting a 4- to 8-week PPI trial in patients with heartburn, regurgitation, or noncardiac chest pains without accompanying alarm signals. If symptoms don’t improve to the patient’s satisfaction, dosing can be boosted to twice per day, or a more effective acid suppressor can be substituted and continued at a once-daily dose. When the response to PPIs is adequate, the dose should be reduced until the lowest effective dose is reached, or the patient could potentially be moved to H2 receptor antagonists or other antacids. However, patients with erosive esophagitis, biopsy-confirmed Barrett’s esophagus, or peptic stricture must stay on long-term PPI therapy.
The authors also gave advice on when to conduct objective testing. When a PPI trial doesn’t adequately address troublesome heartburn, regurgitation, and/or noncardiac chest pain, or if alarm systems are present, endoscopy should be employed to look for erosive reflux disease or long-segment Barrett’s esophagus as conclusive evidence for GERD. If these are absent, prolonged wireless pH monitoring while a patient is off medication is suggested. In addition, patients with extraesophageal symptoms suspected to be caused by reflux should undergo upfront objective reflux testing while off PPI therapy rather than doing an empiric PPI trial.
The authors advise that, if patients don’t have proven GERD and are continued on PPI therapy, they should be evaluated within 12 months to ensure that the therapy and dose are appropriate. Physicians should offer endoscopy with prolonged wireless reflux monitoring in the absence of PPI therapy (ideally after 2-4 weeks of withdrawal) to confirm that long-term PPI therapy is needed.
