2014

New Treatment Guidelines on Gastroesophageal Reflux Disease (GERD) Published by The American College of Gastroenterology

BETHESDA, Md., March 5, 2013 /PRNewswire-USNewswire/ -- New treatment guidelines on the diagnosis and management of gastroesophageal reflux disease (GERD), one of the most prevalent digestive disorders, appear in the March issue of The American Journal of Gastroenterology.

The new guidelines from the American College of Gastroenterology provide an overview of GERD and its presentation and offer clinical recommendations for the approach to diagnosis and management of this common condition, based on an assessment of the scientific evidence.   Experts Philip O. Katz, MD, FACG, Lauren B. Gerson, MD, MSc, FACG and Marcelo F. Vela, MD, MSCR, FACG review the presentations of risk factors for GERD and provide recommendations for medical, surgical and endoscopic management, including comparative effectiveness of different treatments.

The authors note that GERD is "arguably the most common disease encountered by the gastroenterologist.  It is equally likely that the primary care providers will find that complaints related to reflux disease constitute a large proportion of their practice."  The prevalence of GERD is 10 to 20 percent in the Western world, an epidemiologic estimate based primarily on the typical symptoms of heartburn and regurgitation, according to the new guidelines, which estimate that clinically troublesome heartburn is seen in about 6 percent of the population.

The guidelines also address extraesophageal symptoms including asthma, chronic cough and laryngitis, and complications of GERD such as erosive esophagitis, peptic stricture and Barrett's esophagus, as well as the evaluation and management of patients with refractory GERD symptoms— those treated empirically with medications known as proton pump inhibitors (PPIs) who do not respond to medications.

The guidelines review potential adverse events associated with PPI therapy including headache, diarrhea, and dyspepsia in less than 2 % of users, vitamin and mineral deficiencies, association with community-acquired infections including pneumonia and diarrhea, hip fractures and osteoporosis, and increased cardiovascular events in patients using concomitant clopidogrel therapy.  The guidelines offer the following recommendations on potential risks associated with PPIs:

1. Switching PPIs can be considered in the setting of side-effects.

2. Patients with known osteoporosis can remain on PPI therapy. Concern for hip fractures and osteoporosis should not affect the decision to use PPI long-term except in patients with other risk factors for hip fracture.

3. PPI therapy can be a risk factor for Clostridium difficile infection, and should be used with care in patients at risk.

4. Short-term PPI usage may increase the risk of community-acquired pneumonia. The risk does not appear elevated in long-term users.

5. PPI therapy does not need to be altered in concomitant clopidogrel users as there does not appear to be an increased risk for adverse cardiovascular events.

Not All Lifestyle Modifications Improve GERD
The authors review the evidence of the effectiveness of lifestyle interventions as part of therapy for GERD, particularly the impact of dietary and other lifestyle modifications on lower esophageal sphincter pressure (LESP), esophageal pH, and GERD symptoms.  They note that, "Counseling is often provided regarding weight loss, head of bed elevation, tobacco and alcohol cessation, avoidance of late-night meals, and cessation of foods that can potentially aggravate reflux symptoms including caffeine, coffee, chocolate, spicy foods, highly acidic foods such as oranges and tomatoes, and foods with high fat content."   However, based on a review of the evidence, the new guidelines conclude that "routine global elimination of food that can trigger reflux (including chocolate, caffeine, alcohol, acidic and / or spicy foods) is not recommended in the treatment of GERD."  However, multiple studies have demonstrated reduction in GERD symptoms with weight loss.

An evaluation of clinical trials on the effectiveness of various lifestyle modifications finds evidence in support the some of these common lifestyle modifications, yet little or no evidence for others:  "Consumption of tobacco (12 trials), chocolate (2 trials), and carbonated beverages (2 trials) and right lateral decubitus position (3 trials) were shown to lower pressure of the lower esophageal sphincter (LES), whereas consumption of alcohol (16 trials), coffee and caffeine (14 trials), spicy foods (2 trials), citrus (3 trials), and fatty foods (9 trials) had no effect. There was an increase in esophageal acid exposure times with tobacco and alcohol consumption in addition to ingestion of chocolate and fatty foods.  However, tobacco and alcohol cessation (4 trials) were not shown to raise LESP, improve esophageal pH, or improve GERD symptoms.  In addition, there have been no studies conducted to date that have shown clinical improvement in GERD symptoms or complications associated with cessation of coffee, caffeine, chocolate, spicy foods, citrus, carbonated beverages, fatty foods, or mint.  A recent systematic review concluded that there was lack of evidence that consumption of carbonated beverages causes or provokes GERD."

Full text of the ACG GERD guidelines is available from The American Journal of Gastroenterology and experts are available for comments.

About the American College of Gastroenterology
Founded in 1932, the American College of Gastroenterology (ACG) is an organization with an international membership of more than 12,000 individuals from 80 countries.  The College is committed to serving the clinically oriented digestive disease specialist through its emphasis on scholarly practice, teaching and research.  The mission of the College is to serve the evolving needs of physicians in the delivery of high quality, scientifically sound, humanistic, ethical, and cost-effective health care to gastroenterology patients.   www.gi.org  Follow ACG on Twitter

SOURCE American College of Gastroenterology



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