The Agency for Healthcare Research and Quality, or AHRQ, has released guides outlining the risks and benefits of various management options for gastroesophageal reflux disease, or GERD, for clinicians and adult patients.
The guides are based on a comparative effectiveness review(effectivehealthcare.ahrq.gov) of 166 clinical studies that was conducted by researchers at Tufts Medical Center Evidence-based Practice Center in Boston. (An executive summary(effectivehealthcare.ahrq.gov) of the review is available on the AHRQ website.)
GERD is a common health problem in the United States, affecting about 4 percent of U.S. adults.
"Because it affects so many Americans, GERD is an important disease both in terms of public health and cost," said AHRQ Director Carolyn Clancy, M.D., in a Sept. 23 press release. "These new publications will help patients and their clinicians work together to find the best treatment option based on patient preferences and needs."
The goals of treatment for chronic GERD include symptom improvement; enhanced quality of life; management of erosive esophagitis; and prevention of complications, such as esophageal stricture.
Depending on the severity of symptoms and the patient's response to treatment, intermittent (on-demand), periodic or continual use of prescription or OTC medications -- especially histamine type 2 receptor antagonists, or H2RAs, and proton pump inhibitors, or PPIs -- may be used. Standard treatment may involve an eight-week trial of a PPI, in addition to lifestyle modifications.
- The Agency for Healthcare Research and Quality has published clinician and consumer guides that compare the benefits and risks of treatment for gastroesophageal reflux disease, or GERD.
- Proton pump inhibitors are superior to H2RAs in treating the symptoms of GERD.
- Surgical treatment is effective, as well, but has more side effects than medication.
According to the clinician guide, PPIs are superior to H2RAs when treating the symptoms of GERD. In addition, PPIs help to heal esophagitis and provide more patient satisfaction overall.
Although the guide found few consistent differences among different PPIs or among different PPI dosages and dosing regimens, limited studies have suggested that daily dosing, compared with on-demand dosing, may be more effective at improving symptoms and quality of life at six months. Possible side effects of PPIs include diarrhea, nausea, abdominal pain, headaches, intestinal infection, dyspepsia, pneumonia and increased risk of bone fracture.
Surgery appears to be as effective as medical treatment through as long as three years of follow-up. Specifically, fundoplication has been shown to be at least as effective as continued medical treatment for control of GERD symptoms. The side effects associated with surgery, however, are greater than those seen with the use of medication. In addition, some patients (e.g., those who are older or female, have morbid obesity or baseline esophagitis) may be less-than-ideal surgical candidates.
The clinician guide advises health care professionals to discuss the following issues with their patients:
- the difference between heartburn and GERD,
- potential complications of untreated GERD,
- the importance of consistent use of medications,
- OTC options for medical treatment,
- an FDA warning about concomitant use of clopidogrel and omeprazole, and
- the comparative advantages and disadvantages of medical and surgical treatments.
The guide for patients covers the following topics:
- management of GERD may require a number of lifestyle changes, such as maintaining a healthy weight, quitting smoking, not drinking alcohol and avoiding foods that worsen the condition (e.g., spicy or fatty foods);
- several treatment options are available, and any given treatment's effectiveness varies from patient to patient;
- medication is typically a first choice for patients;
- surgery can improve GERD symptoms and decrease the amount of medication patients may need to control their symptoms; and
- endoscopic procedures are an option for the treatment of GERD, but these are newer surgical procedures and they still are being studied, so less is known about how effective and safe they are.