GERD
Maria G. Tanzi, PharmD
Appropriate use of proton pump inhibitors (PPIs) and a review of lifestyle modifications are key topics included in the updated guideline from the American College of Gastroenterology (ACG) on the management of gastroesophageal reflux disease (GERD). This guideline, which was released online in November 2021 and published in the January 2022 issue of The American Journal of Gastroenterology, updates recommendations from almost a decade ago.
Safety of PPIs
PPIs remain the treatment of choice for GERD. ACG recommends an 8-week trial of empiric PPIs once daily before a meal for anyone with typical GERD symptoms (e.g., heartburn, regurgitation) but who have no alarm symptoms, which can include difficulty swallowing or painful swallowing.
If patients respond to the 8-week trial, then ACG recommends an attempt to discontinue the PPI. If maintenance therapy is needed for management of GERD symptoms, then patients should be treated with the lowest effective PPI dose that controls the symptoms and maintains healing of reflux esophagitis. ACG noted that if symptoms resolve over time, then it’s possible to try to discontinue treatment.
On-demand or intermittent use of PPIs is also listed as a treatment option for heartburn symptom control in those with nonerosive reflux disease. ACG also recommends PPIs over histamine-2 receptor antagonists for the management of erosive esophagitis for both healing and maintenance.
In recent years, numerous publications have focused on the long-term safety of PPIs, with many of these published reports raising concern among clinicians about use of PPI medications. ACG discussed this issue in the new guideline and includes talking points for clinicians to consider when discussing the safety of PPIs with patients.
Lifestyle modifications
ACG discussed appropriate lifestyle modifications in detail in the new guideline, with the organization acknowledging that the data supporting these recommendations are limited and variable.
Weight loss is recommended for patients who are overweight or obese to improve GERD symptoms. ACG also recommends avoiding meals within 2 to 3 hours of bedtime, bedtime snacks, and tobacco products.
Improvement of nocturnal GERD symptoms have also been observed in those sleeping with the head of their bed elevated or sleeping on a wedge. Sleeping on the left side may also help with symptoms.
Avoidance of food triggers that may aggravate reflux symptoms are discussed in the guideline, with coffee, chocolate, carbonated beverages, spicy foods, acidic foods (e.g., citrus, tomatoes), and foods high in fat content mentioned. One study found that substituting water for 2 servings of coffee, tea, or soda was associated with a decrease in GERD symptoms. Specific triggers may vary, so patients will need to determine which foods result in GERD symptoms and then make a concerted effort to avoid them. ■
ACG suggested advising patients as follows:
- PPIs are the most effective medical treatment for GERD. Some medical studies have identified an association between the long-term use of PPIs and the development of numerous adverse conditions including intestinal infections, pneumonia, stomach cancer, osteoporosis-related bone fractures, chronic kidney disease, deficiencies of certain vitamins and minerals, heart attacks, strokes, dementia, and early death.
- Those studies have flaws, are not considered definitive, and do not establish a cause-and-effect relationship between PPIs and the adverse conditions.
- High-quality studies have found that PPIs do not significantly increase the risk of any of these conditions except intestinal infections.
- Nevertheless, we cannot exclude the possibility that PPIs might confer a small increase in the risk of developing these adverse conditions.
- For the treatment of GERD, gastroenterologists generally agree that the well-established benefits of PPIs far outweigh their theoretical risks.