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Posted on 11/01/11
JJ, a 60-year-old woman, presents to her primary care office with complaints of heartburn, occurring mainly after eating and especially at night. The patient also reports experiencing nausea, regurgitation, and severe burning in her chest after eating spicy food. After a complete physical examination and referral for tests to rule out other causes, JJ is diagnosed with gastroesophageal reflux disease (GERD). The patient also has a history of asthma, and 6 months earlier she fractured her hip following a fall. Based on this patient’s diagnosis and medical history, what would you advise as effective treatment options for managing her GERD?
Gastroesophageal reflux disease (GERD) is characterized by symptoms that typically include heartburn and regurgitation, as well as nausea, vomiting, early satiety, bloating, and belching.1 Extraesophageal complications include pulmonary disorders and diseases such as asthma, dyspnea, recurrent aspirations, or bronchiectasis. Irritation of the squamous epithelium lining the esophagus can cause erosion of the esophageal mucosa. In Barrett’s esophagus, a disorder in which the esophageal lining is damaged by stomach acid, there is a significant risk of progression to adenocarcinoma.
The mainstay medical treatments for lowering acid levels in the stomach are proton pump inhibitors (PPIs) and histamine-2 receptor antagonists (H2RAs). Administered in an enteric-coated tablet or capsule, PPIs pass through the stomach and are absorbed by the proximal small bowel, with a short half-life of 1-2 hours. In patients with GERD, PPIs can be effective acid suppressants in reducing typical GERD symptoms, including heartburn and regurgitation after meals.2 H2RAs block the histamine receptor on parietal cells, thereby inhibiting the production of acid in the stomach.
Other options for the treatment of GERD include surgery, or fundoplication, which involves wrapping the top portion of the stomach around the lower part of the esophagus to prevent acid reflux. In endoscopic procedures, a tube is extended from the mouth to the esophagus, allowing the clinician to view the esophagus and determine appropriate interventions. Different endoscopic treatments are used to suture or tighten the junction between the stomach and esophagus, which inhibits gastric reflux. Some common types include EndoCinch™, Stretta®, and Esophyx™.
In June 2011, the Agency for Healthcare Research and Quality (AHRQ) published an updated comparative effectiveness review of medical (pharmacologic), surgical, and endoscopic treatments for GERD and its extraesophageal complications.3 For improving GERD symptoms including heartburn, esophageal healing rate, and remission, PPIs were found to be more effective than H2RAs. In a study comparing esomeprazole with ranitidine for 6 months, 80.2% of patients (n = 1,902) taking the PPI esomeprazole 20 mg once daily continuously significantly improved all symptoms, compared with 47.0% of patients taking ranitidine 150 mg twice daily continuously. In addition, 77.8% of patients taking esomeprazole on-demand 40 mg once daily experienced improvements in all symptoms compared with 47.0% of patients taking ranitidine 150 mg twice daily (P < 0.001).4 In another study, the percentages of patients who did not experience heartburn were significantly greater in the esomeprazole once daily arm (72.2%) and esomeprazole on-demand arm (47.0%) than in the ranitidine twice daily arm (32.5%; P < 0.01).5
Although the relationship between acid-suppressive drugs and bone health is uncertain, some experts have speculated that PPI use may interfere with bone metabolism and decrease calcium absorption, thereby increasing the risk for fractures. Data from 7 case-control studies and 2 cohort studies included in the AHRQ review illustrated a potential association between PPI use for longer than 1 year and an increased risk for hip fractures in older adults (≥45 years of age). However, the data come from observational studies, which are subject to confounding influences; in addition, the magnitude of risk remains unclear.3
Overall, there was greater symptom relief and better quality of life outcomes for patients who underwent surgery compared with medical treatment. However, surgical procedures were associated with more adverse events than medical treatment. Fundoplication was associated with more cases of bloating and dysphagia. Common adverse events relating to endoscopic suturing included chest or abdominal pain, bleeding, dysphagia, and bloating.3
Evidence from the AHRQ review indicated that, compared with H2RAs, PPIs provide greater relief of heartburn and healing of esophagitis. In addition, no differences in the effectiveness between different PPIs were found for the prevention of heartburn. GERD can be associated with extraesophageal symptoms including asthma; however, due to insufficient research evidence, the effectiveness of PPIs in relieving asthma is uncertain. In studies comparing prescription versus over-the-counter PPIs, no consistent differences were reported for symptom relief and esophagitis healing rates.3 The side effects associated with PPIs and H2RAs were headaches, diarrhea, nausea, and vomiting. PPIs have also been associated with intestinal infections and pneumonia. Although concomitant use of drugs including clopidogrel and PPIs were not addressed in this review, the EPC investigators urge clinicians to pay close attention to FDA statements in carefully assessing drug interactions.
- Gerson LB, Kahrilas PJ, Fass R. Insights into gastroesophageal reflux disease-associated dyspeptic symptoms. Clin Gastroenterol Hepatol. 2011;9(10):824-833.
- Vanderhoff BT, et al. Proton pump inhibitors: an update. Am Fam Physician. 2002;66(2):273-280.
- Ip S, Chung M, Moorthy D, et al. Comparative Effectiveness of Management Strategies for Gastroesophageal Reflux Disease: Update. Comparative Effectiveness Review No. 29. Rockville, MD: Agency for Healthcare Research and Quality. September 2011. http://www.effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productID=755.
- Hansen AN, Bergheim R, Fagertun H, et al. Long-term management of patients with symptoms of gastro-oesophageal reflux disease—a Norwegian randomised prospective study comparing the effects of esomeprazole and ranitidine treatment strategies on health-related quality of life in a general practitioners setting. Int J Clin Pract. 2006;60(1):15-22.
- Norman HA, Bergheim R, Fagertun H, Lund H, Moum B. A randomised prospective study comparing the effectiveness of esomeprazole treatment strategies in clinical practice for 6 months in the management of patients with symptoms of gastroesophageal reflux disease. Int J Clin Pract. 2005;59(6):665-671.
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