Although proton pump inhibitors have become the mainstay of treatment in gastro-oesophageal reflux disease (GORD), there are still unmet needs in the management of this very common disorder. For example, all current proton pump inhibitors have a relatively slow onset of action and their activity is limited mainly to the post-prandial period with far less effective inhibition of nocturnal acid secretion. In order to achieve more potent, rapid and sustained acid inhibition several compounds are currently under development, such as new proton pump inhibitors with a prolonged plasma halflife, potassium competitive ATPase blockers (PCABs), histamine H 3 agonists, and gastrin antagonists. Acid suppression does not, however, cure the disease and relapses are frequently observed after discontinuation of proton pump inhibitor therapy. Among the different abnormalities involved in the pathophysiology of this multifactorial disease, transient lower oesophageal sphincter relaxations represent the major mechanism responsible for episodes of reflux. Baclofen, the prototype GABA B receptor agonist, is one of the most potent inhibitors of transient lower oesophageal sphincter relaxations identified. To date the transfer of these relaxation-controlling pharmacological agents into clinical practice has however been hampered by the occurrence of unacceptable side effects. Beside ''anti-relaxation therapy'', the potential of novel prokinetics such as motilin agonists has been explored, especially since the motilin receptor has been cloned. Thus far the broad therapeutic value of prokinetics in GORD does, however, seem very limited in terms of efficacy with respect to oesophageal motility and acid exposure. Lastly, further research is necessary to better understand the complex mechanisms involved in oesophageal sensitivity and mucosal defence.Although the aetiology of gastro-oesophageal reflux disease (GORD) is not precisely understood, its pathogenesis is clearly multifactorial; thus, there are many different potential therapeutic targets for drug development. Dysfunction of the lower oesophageal sphincter, the resultant reflux of gastric (and at times duodenal) contents into the oesophagus and the subsequent harmful effects of acid and pepsin on the oesophageal mucosa have been best identified, though they are not the only pathophysiological factors in GORD. During recent decades the central role of acid in the pathophysiology of both GORD symptoms and reflux oesophagitis has largely been confirmed by the therapeutic revolution of proton pump inhibitors. In contrast, the pharmacological control of mechanisms that ultimately result in the occurrence of reflux episodes has been far less successful. Gastro-oesophageal junction incompetence can result from various motility disturbances which are frequently but not necessarily associated with anatomical abnormalities (hiatus hernia). Transient relaxations of the lower oesophageal sphincter are typically not induced by swallowing and represent the major mechanAuthor for corres...