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Table of Contents

• Focus of Research for Clinicians
• Background
• Conclusion
• Clinical Bottom Line
• Gaps in Knowledge
• Additional Issues
• What To Discuss With Your Patients
• Resource for Patients
• Source
• Ordering Information

Focus of Research for Clinicians

As an update to a 2005 report, a systematic review of 166 clinical studies published between January 2004 and August 2010 examined the comparative effectiveness, benefits, and adverse effects of treatments for gastroesophageal reflux disease (GERD) and investigated whether there are factors that influence or predict treatment effectiveness. The review did not evaluate diagnostic approaches, treatment options for patients with refractory symptoms, or the effect of lifestyle modifications on GERD symptoms. The full report, listing all studies, is available at www.effectivehealthcare.ahrq.gov/gerdupdate.cfm. This summary, based on the full report of research evidence, is provided to inform discussions of options with patients and to assist in decisionmaking along with consideration of a patient’s values and preferences. However, reviews of evidence should not be construed to represent clinical recommendations or guidelines.

Background

Chronic GERD is a common health condition resulting from frequent exposure of the esophagus to gastric contents, such as acid and pepsin, that may be harmful to the esophageal epithelium. The physiological barrier to reflux is the lower esophageal sphincter (LES), which is anchored by the crural diaphragm. The function of the antireflux barrier may be compromised by a hiatal hernia or a hypotensive LES, alone or in combination.

The goals of therapy for chronic GERD include improvement in symptoms and quality of life, healing of erosive esophagitis, and prevention of complications such as esophageal stricture. However, considerable uncertainty remains about how these objectives should be achieved. If left untreated, chronic GERD can cause esophagitis, esophageal ulcers, bleeding, scarring of the esophagus, or Barrett’s esophagus.

Medical treatment of GERD consists of pharmacological suppression of gastric acid, which is generally the first line of treatment. Depending on the severity of symptoms and clinical response, intermittent (on-demand), periodic, or continuous use of prescription or over-the-counter medications—especially histamine type 2 receptor antagonists (H2RAs) and proton pump inhibitors (PPIs)—have been used. Standard treatment may involve an 8-week trial of a PPI, along with lifestyle modification.

Surgical management of GERD, which consists of repairing and/or strengthening the physiological antireflux barrier, represents another treatment option. Endoscopic treatments have recently become available and are currently being studied.

Conclusion

PPIs are superior to H2RAs for treating chronic GERD. Comparisons among different PPIs or among different dosages and dosing regimens of PPIs show few consistent differences. Limited studies suggest that continuous daily dosing provides improved symptom control and quality of life at 6 months when compared to on-demand dosing. Through up to 3 years of followup, surgery appears to be as effective as medication, but serious adverse effects may be more common with surgical treatments. Evidence to evaluate endoscopic treatments is lacking.

Clinical Bottom Line

Strength of Evidence Scale

High:
There are consistent results from good-quality studies. Further research is very unlikely to change the conclusions.

Moderate: 
Findings are supported, but further research could change the conclusions.

Low:
There are very few studies, or existing studies are flawed.

Insufficient:
Research is either unavailable or does not permit estimation of a treatment effect.

Gaps in Knowledge

• Due to a paucity of studies, the long-term comparative benefits and adverse effects of laparoscopic fundoplication versus medical treatments cannot be determined. The potential for lifelong PPI or H2RA treatment necessitates the study of long-term safety concerns.
• Most studies do not evaluate options for patients whose GERD does not respond well to medications.
• Evidence is lacking to determine the role, safety, and value of endoscopic procedures.
• Evidence is sparse regarding the treatment of extraesophageal manifestations of GERD.

Additional Issues

• An October 2010 reminder from the U.S. Food and Drug Administration (FDA) warns that the concomitant use of clopidogrel and the PPI omeprazole can result in significant reductions in clopidogrel’s antiplatelet activity.

What To Discuss With Your Patients

• The difference between heartburn and chronic GERD.
• The potential risks for complications from untreated GERD.
• The need for consistent use of medications if prescribed.
• The availability of GERD medications without prescription.
• The FDA warning about clopidogrel and omeprazole.
• The advantages and disadvantages of medical versus surgical treatment.

Resource for Patients

Treatment Options for GERD or Acid Reflux Disease, A Review of the Research for Adults is a free companion to this clinician research summary. It provides:

• A description of GERD, its symptoms, and potential outcomes if untreated.
• Descriptions of the types of treatments, how they work, and potential side effects.
• Questions to guide a discussion about treatment options.

Source

The information in this summary is based on Management Strategies for Adults With Gastroesophageal Reflux Disease — An Update, Comparative Effectiveness Review No. 29, prepared by the Tufts Medical Center Evidence-based Practice Center under Contract No. HHSA-290- 2007-10055-I for the Agency for Healthcare Research and Quality, September 2011. Available at www.effectivehealthcare.ahrq.gov/gerdupdate.cfm. 

This summary was prepared by the John M. Eisenberg Center for Clinical Decisions and Communications Science at Baylor College of Medicine, Houston, TX. It was written by Emily White, M.S., Amelia Williamson Smith, M.S., Thomas Workman, Ph.D., Marcelo Vela, M.D., and Michael Fordis, M.D. 

Ordering Information

For free print copies of this guide, call 800-358-9295. Ask the Publications Clearinghouse for AHRQ Publication 11-EHC-049-3.

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