A new 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.
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.
In the section on personalization of disease management, the authors note that ambulatory reflux monitoring and upper gastrointestinal endoscopy can be used to guide management of GERD. When upper GI endoscopy reveals no erosive findings and esophageal acid exposure time (AET) is less than 4% throughout all days of prolonged wireless pH monitoring, the physician can conclude that the patient has no pathologic gastroesophageal reflux and is likely to have a functional esophageal disorder. In contrast, erosive findings during upper GI endoscopy and/or AET more than 4% across at least 1 day of wireless pH monitoring suggests a GERD diagnosis.
Optimization of PPI is important among patients with GERD, and the authors stress that patients should be educated about the safety of PPI use.
Adjunctive pharmacotherapy is useful and can include alginate antacids for breakthrough symptoms, H2RAs for nocturnal symptoms, baclofen to counter regurgitation or belching, and prokinetics for accompanying gastroparesis. The choice of medications depends on the phenotype, and they should not be used empirically.
For patients with functional heartburn or reflux disease linked to esophageal hypervigilance, reflux sensitivity, or behavioral disorders, options include pharmacologic neuromodulation, hypnotherapy provided by a behavioral therapist, cognitive behavioral therapy, and diaphragmatic breathing and relaxation.
If symptoms persist despite efforts at optimization of treatments and lifestyle factors, ambulatory 24-hour pH-impedance monitoring on PPI can be used to investigate mechanistic causes, especially when there is no known antireflux barrier abnormality, but the technique requires expertise to correctly interpret. This can ensure that the symptoms are not due to reflux hypersensitivity, rumination syndrome, or a belching disorder. When symptoms are confirmed to be treatment resistant, therapy should be escalated, using a strategy that incorporates a pattern of reflux, integrity of the antireflux barrier, obesity if present, and psychological factors.
Surgical options for confirmed GERD include laparoscopic fundoplication and magnetic sphincter augmentation. Transoral incisionless fundoplication can be performed endoscopically in selected patients. For obese patients with confirmed GERD, Roux-en-Y gastric bypass is effective at reducing reflux and can be used as a salvage treatment for nonobese patients. Sleeve gastrectomy may 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.
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