A new clinical practice update from the American Gastroenterological Association for the evaluation and management of gastroesophageal reflux disease (GERD) focuses on providing personalized diagnostic and therapeutic strategies.
The document includes new guidance on the use of initial objective testing for isolated extra-oesophageal symptoms, confirmation of the diagnosis of GERD before long-term treatment of GERD, even in PPI responders, and important points focused on personalization of treatment.
Although GERD is common, with approximately 30% of people in the United States experiencing symptoms, up to half of all people on proton pump inhibitor (PPI) therapy report incomplete improvement in symptoms. This could be due to the heterogeneous nature of the symptoms, which may include heartburn and regurgitation, chest pain, and cough or sore throat, among others. Other conditions may produce similar symptoms or may be exacerbated by the presence of GERD.
The authors of the expert review, published in Clinical Gastroenterology and Hepatology, note that these considerations have led to increased interest in personalized approaches to GERD management. The practice update includes sections on how to approach GERD symptoms in the clinic, personalized diagnosis related to GERD symptoms, and precision management.
In initial management, the authors offer guidance on involving the patient in creating a care plan, educating the patient, and conducting a 4- to 8-week PPI trial in patients with heartburn, regurgitation, or non-cardiac chest pain without associated red flags. If symptoms do not improve to the patient’s satisfaction, the dosage may be increased to twice daily, or a more effective acid suppressant may 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, otherwise the patient may need to take H2-receptor antagonists or other antacids. However, patients with erosive esophagitis, biopsy-confirmed Barrett’s esophagus, or peptic stricture should remain on long-term PPI therapy.
The authors also gave advice on when to perform objective tests. When a PPI trial does not adequately treat troublesome heartburn, regurgitation, and/or non-cardiac chest pain, or if alarm systems are present, endoscopy should be used to look for a erosive reflux or a long-segment Barrett’s esophagus as conclusive evidence of GERD. If these are absent, extended wireless pH monitoring while a patient is not on medication is suggested. Additionally, patients with extra-esophageal symptoms suspected of being caused by reflux should undergo an initial objective reflux test when not on PPI therapy rather than doing an empiric PPI test.
The authors advise that if patients do not have established GERD and continue to receive PPI therapy, they should be evaluated within 12 months to ensure that the treatment and dose are appropriate. Physicians should offer endoscopy with extended 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.
In the section on personalizing disease management, the authors note that ambulatory reflux monitoring and upper gastrointestinal endoscopy can be used to guide management of GERD. When upper gastrointestinal endoscopy reveals no erosive findings and esophageal acid exposure time (ETA) is less than 4% during all days of extended wireless pH monitoring, the physician may conclude that the patient does not have gastroesophageal reflux disease and is likely to have a functional esophagus. mess. In contrast, erosive findings during upper gastrointestinal endoscopy and/or TEI of greater than 4% over at least 1 day of wireless pH monitoring suggest a diagnosis of GERD.
Optimization of PPIs is important in patients with GERD, and the authors emphasize that patients should be informed about the safety of using PPIs.
Adjuvant drug therapy is helpful and may include alginate antacids for flare symptoms, H2 blockers for nocturnal symptoms, baclofen to counter regurgitation or belching, and prokinetics to accompany gastroparesis. The choice of drugs depends on the phenotype and they should not be used empirically.
For patients with functional heartburn or reflux related to esophageal hypervigilance, reflux sensitivity, or behavioral disturbances, options include pharmacological neuromodulation, hypnotherapy provided by a behavioral therapist, cognitive therapy -behavioral and diaphragmatic breathing and relaxation.
If symptoms persist despite efforts to optimize treatments and lifestyle factors, 24-hour ambulatory pH impedance monitoring on PPI can be used to investigate mechanistic causes, particularly when there is no There is no known anomaly of the antireflux barrier, but the technique requires expertise to interpret correctly. This can ensure that the symptoms are not due to reflux hypersensitivity, rumination syndrome or belching disorder. When symptoms are confirmed to be resistant to treatment, treatment should be intensified, using a strategy that incorporates a reflux pattern, the integrity of the anti-reflux barrier, obesity if present, and psychological factors.
Surgical options for confirmed GERD include laparoscopic fundoplication and magnetic sphincter augmentation. Incisionless transoral fundoplication can be performed endoscopically in selected patients. For obese patients with confirmed GERD, Roux-en-Y gastric bypass is effective in reducing reflux and can be used as a salvage treatment for non-obese patients. Sleeve gastrectomy can exacerbate GERD.
The authors reported relationships with Medtronic, Diversatek, Ironwood, and Takeda. The authors also reported funding from National Institutes of Health grants.
This article originally appeared on MDedge.com, part of the Medscape Professional Network.