Comparison of Short-Term Treatments for GERD
Which medications improve outcomes in patients with symptoms of gastroesophageal reflux disease (GERD) who are treated empirically and in those with symptoms but a normal endoscopy?
For empiric treatment of GERD or endoscopy-negative reflux disease, a short trial of a proton pump inhibitor increases the chance of remission. Histamine H2-receptor antagonists are less expensive and work well in many patients, particularly those with less severe symptoms or endoscopy-negative reflux disease.
GERD is extremely common, and most patients are treated empirically. Endoscopy can diagnose esophagitis, ulcers, bleeding, strictures, Barrett’s esophagus, and carcinoma. Urgent upper endoscopy should be performed in patients with melena, hematemesis, persistent vomiting, anemia, acute onset of total dysphagia, or involuntary weight loss of more than 5 percent of total body weight. Patients older than 45 to 50 years should receive nonurgent endoscopy. Younger patients should be considered for endoscopy if they are at risk for gastric cancer.1–2 Pinxeren and colleagues reviewed the literature to determine which treatments benefit patients with symptoms of GERD who are treated empirically, and which options are effective in patients with GERD symptoms but a normal endoscopy.
The authors found 27 trials with 8,402 participants ranging from 18 to 79 years of age (mean age, 48 years); 45 percent of participants were men. Most of the trials were of adequate quality. Patients who were treated empirically had a remission in heartburn when they received proton pump inhibitors (relative risk [RR], 0.37; 95 percent confidence interval [CI], 0.32 to 0.44) and histamine H2-receptor antagonists (RR, 0.77; 95 percent CI, 0.60 to 0.99). In direct comparisons, proton pump inhibitors were significantly more effective than histamine H2-receptor antagonists and prokinetics in achieving remission. No significant differences were noted between proton pump inhibitors and histamine H2-receptor antagonists in patients with endoscopy-negative reflux disease.
The results of this study did not identify differences between proton pump inhibitors (such studies are lacking). Because many patients do well with a histamine H2-receptor antagonist at much lower cost, these drugs still should be considered viable treatment options for many patients. The cost difference between the newest proton pump inhibitor (rabeprazole; $4.50 per day) and generic omeprazole (less than $1 per day) or ranitidine (less than $0.50 per day) is substantial.