CAG GERD guideline update discusses increased monitoring of PPI therapy

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December 3, 2021 — For the first time since 2013, the American College of Gastroenterology (ACG) has released updated evidence-based recommendations and practical guidance on the evaluation and management of gastroesophageal reflux disease (GERD) , including pharmacology, lifestyle, surgical and endoscopic management.

Over the past 8 years, the understanding of the varied presentations of GERD, improvements in diagnostic testing and the approach to patient management have evolved, and there has been greater scrutiny of inhibitor therapy. the proton pump (PPI) and its potential side effects, the guideline authors say.

While PPIs remain the “medical treatment of choice” for GERD, several studies have raised questions about adverse events, they note.

“We now know a lot more about the adverse effects of PPIs in the sense that we still have 8 years of experience” since the 2013 guideline, says first author Philip O. Katz, MD, professor of medicine and director of laboratories motility at Weill Cornell Medicine, New York City.

This update emphasizes the importance of making an accurate diagnosis and recommends PPI therapy “when patients are truly experiencing GERD and be careful to use the lowest effective dose,” Katz says.

The guideline was published online November 22 in the American Journal of Gastroenterology.

The benefits outweigh the risks

The guideline suggests telling patients that PPIs are the most effective medical treatment for GERD.

Some studies have identified an association between long-term use of PPIs and the development of several adverse conditions, including intestinal infections, pneumonia, stomach cancer, osteoporosis-related bone fractures, kidney disease chronic, deficiencies of certain vitamins and minerals, heart attacks. , strokes, dementia and premature death.

Clinicians should point out, however, that these studies have flaws, are not considered definitive, and do not establish a causal relationship between PPIs and adverse conditions.

They should also emphasize to patients that high-quality studies have shown that PPIs do not significantly increase the risk of any of these conditions except intestinal infections.

Patients should be informed that for the treatment of GERD, “gastroenterologists generally agree that the well-established benefits of PPIs far outweigh their theoretical risks”.

“Everything about this guideline makes sense,” says Scott Gabbard, MD, gastroenterologist and section chief at the Cleveland Clinic Center for Neurogastroenterology and Motility, who was not involved in the development of the guideline. .

“A trial of PPIs for anyone with typical GERD symptoms and for those who respond to the lowest effective dose remains the first line for anyone with GERD,” says Gabbard.

Diagnose

As there is no gold standard for the diagnosis of GERD. Diagnosis is based on a combination of symptoms, endoscopic evaluation of the esophageal lining, monitoring of reflux and response to therapeutic intervention, the guideline states.

For patients with classic symptoms of heartburn and regurgitation without alarm symptoms, the authors recommend an 8-week trial of empiric PPIs once daily before a meal. If the patient responds, the guideline recommends trying to stop the drug.

The guideline recommends diagnostic endoscopy after discontinuation of PPIs for 2–4 weeks in patients whose classic symptoms do not respond adequately to the 8-week empirical PPI trial or in those whose symptoms recur when PPIs are stopped.

For patients with chest pain but no heartburn who have had adequate evaluation to rule out heart disease, the guideline recommends objective testing for GERD (endoscopy and/or reflux monitoring).

Use of barium swallow alone as a diagnostic test for GERD is not recommended.

Endoscopy should be the first test to assess patients with dysphagia or other alarming symptoms, such as weight loss and gastrointestinal bleeding, as well as patients with risk factors for Barrett’s esophagus .

For patients in whom the diagnosis of GERD is suspected but unclear and where endoscopy fails to show objective evidence of GERD, guidelines advise monitoring off-treatment reflux to establish the diagnosis.

The guideline advises against off-therapy reflux monitoring only as a diagnostic test for GERD in patients with known endoscopic evidence of Los Angeles (LA) grade C or D reflux esophagitis or in patients with esophagus of Barrett with long segment.

High-resolution manometry used only as a diagnostic test for GERD is also not recommended.

Medical management of GERD

Recommendations for the medical management of GERD include weight loss in overweight or obese patients, avoidance of meals within 2-3 hours of bedtime, avoidance of tobacco products and trigger foods, and elevation of the head of the bed for nocturnal symptoms.

Treatment with a PPI is recommended over histamine-2 receptor antagonists for healing and maintaining healing of eosinophilic esophagitis. It is recommended to take a PPI 30-60 minutes before a meal rather than at bedtime.

“Use of the lowest effective PPI dose is recommended and makes sense but should be individualized,” the guideline says.

There is a “conceptual rationale” for a trial of PPI switching for patients who do not respond to a PPI. However, switching more than once to another PUP “cannot be supported,” the guideline says.

Gabbard said the advice on changing PPIs in non-responders is particularly helpful.

“In clinical practice, I see patients who try a PPI, and if it doesn’t work, their doctor puts them on another PPI, then another and another, until they get through five PPIs and don’t go nowhere,” he said.

“This new guideline is very helpful to say that if a patient has GERD symptoms that don’t respond to a PPI, you can make a change. But if that doesn’t work, have a low threshold to do pH testing. to determine if the patient really has reflux or not,” says Gabbard.

“Some studies have suggested that up to 75% of PPI non-responders do not actually have reflux. They have functional heartburn, which is not reflux and is treated without PPI,” notes- he.

One area of ​​controversy concerns the abrupt discontinuation of PPIs and potential rebound acid hypersecretion, leading to increased reflux symptoms. Although this has been seen in healthy control patients, strong evidence of an increase in symptoms after abrupt discontinuation of PPIs is lacking.

The guideline makes “no definitive recommendation as to whether weaning or stopping cold turkey from PPIs is a better approach, due to a lack of evidence,” Katz says.

For patients with GERD without erosive esophagitis or Barrett’s esophagus whose symptoms resolve with PPI therapy, the guideline states that an attempt should be made to discontinue PPI therapy or switch to on-demand therapy in which a PPI is taken only when symptoms occur and is stopped when they are relieved.

For patients with grade C or D LA esophagitis, the recommendation is to continue treatment with PPIs or anti-reflux surgery indefinitely.

Gabbard said it was “nice to have in writing from the ACG that patients with erosive esophagitis or Barrett’s esophagus – those who really need a PPI – should be on PPI treatment indefinitely , as the benefits of a PPI far outweigh the theoretical risks.”

The research had no financial support. Katz has consulted for Phathom Pharma and Medtronic, received research support from Diversatek and royalties from UpToDate, and serves on the advisory board of Medscape Gastroenterology. Gabbard did not disclose any relevant financial relationship.

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