Gastroesophageal reflux disease (GERD) continues to be among the most common diseases seen by gastroenterologists, surgeons, and primary care physicians.

The American College of Gastroenterology (ACG) recently released an updated guideline on diagnosis and management of GERD which was published by the American Journal of Gastroenterology. In this new updates, guidelines provide updated, evidence-based recommendations and practical guidance.

LONG-TERM PPI ISSUES

During this time, scrutiny of proton pump inhibitors (PPIs) has increased considerably. Although PPIs remain the medical treatment of choice for GERD, multiple publications have raised questions about adverse events, raising doubts about the safety of long-term use and increasing concern about overprescribing of PPIs.

Benefits Outweigh Risks

New data regarding the potential diagnosis, management and safety have emerged.

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

These studies have flaws, are not considered definitive, and do not establish a cause-and-effect relationship between PPIs and the adverse conditions.

High-quality studies have found that PPIs do not significantly raise the risk of any of these adverse conditions except intestinal infections.

A PPI trial for anyone with typical GERD symptoms and having those who respond taper to the lowest effective dose is still the first line for anyone with GERD.

Medical Management of GERD

Recommendations for medical management of GERD include weight loss in patients who are overweight or obese, 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 nighttime symptoms.

PPIs are the most commonly prescribed medication based on ample data demonstrating consistently superior heartburn and regurgitation relief, as well as improved healing compared with H2RAs.

Taking a PPI 30–60 minutes prior to a meal rather than at bedtime is recommended.

"Use of the lowest effective PPI dose is recommended and logical but must be individualized," the guideline states.

There is "conceptual rationale" for a trial of switching PPIs for patients who don't respond to one PPI. However, switching more than once to another PPI "cannot be supported," the guideline says.

If a patient has GERD symptoms that do not respond to a PPI, clinicians can do one switch.

For patients with GERD without erosive esophagitis or Barrett's esophagus and whose symptoms resolve with PPI therapy, the guideline says an attempt should be made to discontinue PPI therapy or to 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 LA grade C or D esophagitis, the recommendation is for maintenance PPI therapy indefinitely or antireflux surgery.

This update emphasizes the importance of making an accurate diagnosis and recommends PPI therapy "when patients really have GERD and being careful to use the lowest effective dose,"

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