Heartburn / Gastro-oesophageal reflux disease (GORD) Medical Treatment Guidelines

Heartburn / Gastro-oesophageal reflux disease (GORD) Medical Treatment Guidelines

Aims
For most patients, the aim is acceptable symptom control using the least treatment necessary to achieve this. Therefore, if symptom control is the aim, endoscopy to assess healing of oesophagitis is unnecessary. Indeed, it is now known that, at least for patients treated with proton pump inhibitors, absence of symptoms on treatment equates with healing of oesophagitis. For those with complications, such as stricture or bleeding from oesophagitis, the aim will be long term healing of oesophagitis.
Patients with Barrett’s oesophagus have a risk of between 1 in 50 and 1 in 200 of developing adenocarcinoma of the oesophagus. Many gastroenterologists therefore recommend yearly or biennial endoscopic screening with multiple biopsies to detect dysplasia. Patients with severe dysplasia often have an undetected early cancer and so are offered oesophagectomy. Surveillance of patients with Barrett’s oesophagus to detect severe dysplasia or early cancer is controversial, partly because its benefits have not been established by well designed randomised controlled trials. Clearly a surveillance policy is inappropriate in elderly patients who are unfit for surgery. Endoscopic ablation of the abnormal columnar mucosa in Barrett’s oesophagus by photodynamic laser or thermal methods looks promising and may become standard treatment. It must be combined with high doses of proton pump inhibitors or antirefluxsurgery to prevent continuing acid reflux.

General measures
Patients should be advised to lose weight if overweight. There is no formal evidence to support this assertion, but success (though rarely achieved) may result in improved symptom control. Raising the head of the bed on 15 cm wooden blocks has been shown in a controlled trial to improve symptoms and healing of oesophagitis. There is little evidence that avoidance of specific foods has much effect on the course of the disease, but many patients have already identified and stopped eating foods that produce symptoms before consulting their doctor. Other potentially damaging drug treatment should also be reviewed.
While the benefits associated with these general measures may be unproved, they allow patients to be involved with decision making and may help them avoid over-medicalising their condition.

Antacids and alginates
Antacids are effective for short term relief of symptoms. Although their efficacy is difficult to confirm in controlled trials, many sufferers, particularly those who do not consult a doctor, rely on self medication with antacids. Alginates work by forming a floating viscous raft on top of the gastric contents that provides a physical barrier to prevent reflux. To maximise this effect, they are therefore best taken after meals, otherwise they rapidly empty from the stomach and thus give only transient relief of symptoms by virtue of their antacid content.

Acid suppression therapy
The two major classes of agent available are the H2 receptor antagonists and the proton pump inhibitors. There is little doubt that proton pump inhibitors are more rapidly and completely effective for both relieving symptoms and healing oesophagitis, regardless of disease severity. Because of this, a cost effectiveness argument has been made in favour of proton pump inhibitors as first choice treatments in all cases. However, the data on which these calculations have been made have generally come from hospital based clinical trials and may not be applicable to general practice.
Many patients in primary care may achieve good and lasting symptom relief from short intermittent courses of H2 receptor antagonists at standard doses (such as ranitidine 150 mg twice daily or cimetidine 400 mg twice daily). For patients with severe or refractory oesophagitis, particularly those with complications such as stricture, proton pump inhibitors are the drugs of choice. The optimal daily dose for most patients is omeprazole 20 mg , lansoprazole 30 mg, pantoprazole 40 mg, or rabeprazole 20 mg, but higher doses may give additional clinical benefit in patients with resistant oesophagitis. For most patients, there is no clinical advantage in choosing one proton pump inhibitor over another.

Motility modifying drugs
These include metoclopramide and domperidone. Although both relieve symptoms of heartburn to a degree similar to H2 receptor antagonists, they do not heal oesophagitis. In addition, metoclopramide has a relatively high incidence of side effects on the central nervous system. However, these drugs may be useful, particularly in patients with other dyspeptic symptoms such as nausea or early satiety.

Maintenance treatment
Only proton pump inhibitors, at standard or half standard doses, have been shown to be effective agents for maintenance of remission in those who require it. Indications for maintenance treatment include

•  Severe oesophagitis, especially presenting with complications (such as stricture, bleeding, peptic ulcers)
•  Barrett’s oesophagus (although there is no evidence that continuous treatment prevents evolution to cancer)
•  Symptoms (typical or atypical) relapsing as soon as treatment is stopped.

Surgery
Laparoscopic anti-refluxsurgery seems to be as successful as conventional surgery in controlling refluxin the short term without the disadvantages of a long hospital stay or convalescence. It has become an increasingly popular option for patients requiring long term medical treatment. The results from a randomised controlled trial comparing surgery with maintenance drug treatment are awaited.







References:
- Robert PH Logan. 2002. ABC OF THE UPPER GASTROINTESTINAL TRACT. London: BMJ Books.
- Image Source: http://www.webmd.com/heartburn-gerd/guide/complications-untreated-gerd

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