Overview: initial and long‐term management of gastro‐oesophageal reflux disease

Abstract

Summary Initial management of gastro‐oesophageal reflux disease aims to confirm a symptom‐based diagnosis, to relieve symptoms, to reassure the patient as to the treatable nature of reflux disease, and to initiate risk management and healing of oesophagitis. The aims of long‐term management include adequate control of symptoms, prevention of complications, and improvement of quality of life. Management options in terms of use of proton pump inhibitors are either daily therapy (maintenance), intermittent courses of therapy (for example, 4 weeks, then cease and observe), or on‐demand therapy. This overview discusses the advantages and disadvantages of these different strategies for the management of reflux disease.

Costs and efficacy of three different esomeprazole treatment strategies for long‐term management of gastro‐oesophageal reflux symptoms in primary care

“…An evidence‐based appraisal of reflux disease management – the Genval Workshop Report – identified proton pump inhibitors as the most effective initial and long‐term therapy in GERD patients, and recommended that proton pump inhibitors should be first‐line therapy for the management of GERD 5 . Different maintenance therapies have been suggested: daily low‐dose proton pump inhibitor, on‐demand use of proton pump inhibitor or intermittent treatment courses 6 …”

Medical economy and acid reflux diseases

“…Many issues of cost‐effectiveness on treating GERD remain unknown. For example, it looks debatable whether the currently developing endoluminal therapy or laparoscopic antireflux surgery has a comparable cost‐effectiveness to this of PPI for GERD patients, particularly due to these procedures always having operator dependency and associated complications 2,27 . BE is one of GERD manifestations, though it appears rare among the Asian population 8,28 .…”

“…For example, it looks debatable whether the currently developing endoluminal therapy or laparoscopic antireflux surgery has a comparable cost-effectiveness to this of PPI for GERD patients, particularly due to these procedures always having operator dependency and associated complications. 2,27 BE is one of GERD manifestations, though it appears rare among the Asian population. 8,28 Actually, high-grade dysplasia and adenocarcinoma have been the most well-known complications of BE, particularly among Caucasians with the risk factors of male, elderly, longstanding reflux, long-segment BE etc.…”

Treatment of uncomplicated reflux disease

“…These aims should be achieved at the lowest possible cost and with minimal risks [88] . Initial therapy should via rapid relief of symptoms confirm the symptom based diagnosis, reassure the patient as to the benign and treatable nature of the reflux disease, and if present cure the esophagitis.…”

“…If continuous maintenance therapy is needed to preserve remission, or if an initial positive response is rapidly followed by relapse, an endoscopic evaluation to exclude/detect severe erosive esophagitis or complicated reflux disease is recommended. If initial treatment is not successful, and if the clinical data militate against a severe form of GERD, the PPI dose can be increased (standard dose twice daily) or a changeover to a more potent substance implemented [59] ; otherwise, in this clinical situation, too, endoscopy should be performed [88] . It is not clear whether patients who respond to initial treatment with a PPI and are then well controlled with on-demand therapy need to be submitted to endoscopy at all.…”