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Should Patients With GERD Be Treated Continuously?
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Am Fam Physician. 1999 May 15;59(10):2859-2860.
Continuous treatment with proton pump inhibitors has been widely recommended for long-term management of symptomatic gastroesophageal reflux disease (GERD). However, many patients, particularly those believed to have mild or moderate disease, are given only a short course of medication during symptomatic periods. Bardhan and colleagues studied the effectiveness of intermittent short courses of proton pump inhibitor therapy to control GERD symptoms over a 12-month period.
Patients were recruited for the study from 56 general medical practices in several European countries. Inclusion criteria included normal or mild erosive changes on endoscopy and a history of moderate to severe heartburn that interfered with normal activities for more than two days a week within a two-week period. Patients were randomized to receive omeprazole in a dosage of 10 mg daily, omeprazole in a dosage of 20 mg daily or ranitidine in a dosage of 150 mg twice daily for an initial two-week period. Those who were asymptomatic after seven days were then followed for 12 months to monitor recurrence. Patients who continued to have symptoms received either a double dosage of medication or their initial dosage for another two weeks. Those who were asymptomatic after the second treatment period also entered the follow-up study.
During the follow-up period, patients received no additional treatment unless they reported moderate to severe heartburn at least two days a week within a two-week period or if they took more than three antacid tablets daily to control symptoms. For each recurrence, patients received two or four weeks of the dosage of medication that had resolved their symptoms. Patients were reassessed every three months.
A total of 704 patients enrolled in the study. Of these, 526 reached a treatment-related end point. The median number of days without medication in this group of patients was 281. Recurrence was infrequent, with 40 percent of patients having no relapse, 30 percent having only one, 15 percent having two and 8 percent having three relapses. Symptom control at two weeks was a powerful predictor of no relapse. The only factor linked to relapse was smoking. Omeprazole was superior to ranitidine in controlling symptoms after two weeks, particularly in the higher dosage. However, by the end of 12 months, approximately 22 to 27 percent of patients in each treatment group required long-term maintenance therapy. Of note, intermittent therapy with an initial dosage of 20 mg of omeprazole was deemed the most cost-effective over a 12-month period.
The authors conclude that intermittent treatment is a simple yet practical strategy in general practice, where most of these patients are seen. Intermittent treatment controls the symptoms of moderate, uncomplicated GERD in more than one half of all patients. Relapses are relatively infrequent and usually can be controlled with a short course of treatment.
Bardhan KD, et al. Symptomatic gastro-oesophageal reflux disease: double blind controlled study of intermittent treatment with omeprazole or ranitidine. BMJ. February 20, 1999;318:502–7.
Copyright © 1999 by the American Academy of Family Physicians.
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