Physician's Weekly Article - New Guidance for Managing GERD

       The American Gastroenterological Association Institute has unveiled new guidelines for treating and managing GERD. They stress the use of medications and surgery appropriately, based on emerging evidence from clinical studies.

      GERD is one of the most common gastrointestinal (GI) conditions in the United States. An AHRQ report in 2008 found that hospitalizations for complications resulting from GERD increased by 103% from 1998 to 2005. Although the data are alarming in hospitals, the condition is often cared for by GI specialists and primary care physicians. Several medical organizations have established clinical guidelines for the diagnosis and management of GERD, but many of the physicians who treat the disease rely on empirical trials of medications and their own observations and experience when they manage these patients.

      In 2008, the American Gastroenterological Association (AGA) Institute released evidence-based guidelines for the management and treatment of suspected GERD. Published in the October 2008 issue of Gastroenterology and available for free online at www.gastro.org, the AGA Institute’s guidelines aim to briefly summarize key issues surrounding the diagnosis and treatment of GERD. “Physicians are currently using many methods to treat GERD,” explains Peter J. Kahrilas, MD, who was the lead author of the guidelines. “Unfortunately, many are unaware of the most effective strategies based on the current body of evidence.”

      The AGA Institute’s guidelines are different from those created by other professional organizations because of how they are formatted. “These guidelines are structured around 12 clinical questions that specifically address major management issues that are encountered in patients with GERD in current clinical practice,” says Dr. Kahrilas. “The clinical issues described in the recommendations relate to diagnosis, initial therapy, and chronic management strategies.”

      Assessing Current Management Strategies

      The guidelines indicate that high-quality clinical trials for GERD management strategies do not exist. “Most of the available randomized, controlled clinical trials have assessed pharmacologic therapies for GERD syndromes,” says Dr. Kahrilas. “In other current guidelines, many of the highest-level, evidence-based recommendations address only the acute treatment of heartburn or esophagitis. Consequently, much of the current management of patients with GERD has been based on experiences from physicians, uncontrolled trials, and expert opinion, according to our research. The hope is that the AGA Institute’s guidelines will help clinicians better treat patients who present with suspected GERD.” Dr. Kahrilas added that all conclusions of the technical review and the medical position statement, which are both included in the guidelines, were based on the best available evidence or, in the absence of quality evidence, expert opinions.

      Graded Recommendations

      The strength of the conclusions made in the AGA Institute’s guidelines was determined using grades created by the U.S. Preventive Services Task Force. Dr. Kahrilas says “Grade A recommendations are strongly recommended based on good evidence that the practice improves important health outcomes whereas Grade B recommendations are recommended with fair evidence that they can improve important outcomes [Table 1]. Grade C recommendations are based solely on opinion and grade D recommendations are practices that should be avoided because they do more harm than good, in our opinion.”

      According to Dr. Kahrilas, one of the most important Grade B recommendations is that patients who need proton pump inhibitors (PPIs) should use these therapies twice daily if they have inadequate responses with once-daily use (Table 2). “In treating patients with suspected reflux-chest pain syndromes, twice-daily use of PPIs should only be considered after risks for cardiac problems are explored,” he adds. Dr. Kahrilas notes that research evaluating PPIs and other pharmacotherapies in head-to-head studies would be beneficial for future updates to the recommendations.

      Dr. Kahrilas says that there are several other important Grade B recommendations that can assist clinicians who manage patients with GERD. “It appears that making lifestyle modifications can have a profound impact for patients. Those with GERD who lose weight are more likely to experience reductions in their symptoms. Patients should be informed that weight loss could lead to substantial benefits. While exercise and diet are important for weight loss, it should be noted that dietary changes other than those intended to achieve weight loss appear to have little effect on the reduction of GERD symptoms.”

      Endoscopy & Surgery

      The guidelines also assess the role of endoscopy in GERD, and Dr. Kahrilas says that patients with dysphagia should undergo these procedures. “However, other indications for endoscopy are still unclear. For example, endoscopy has been recommended as a screening test for Barrett’s esophagus, but there isn’t enough evidence to uniformly advocate this practice. In addition to endoscopy, the AGA Institute’s guidelines note when patients should be considered for antireflux surgery. Although medications are often used for GERD patients even after they have surgery, it’s not a recommended practice. The key is to closely monitor patients after the surgery and then determine the need for long-term medication use after the operation.”

      Peter J. Kahrilas, MD, has indicated to Physician’s Weekly that he has served as a consultant for AstraZeneca, Procter & Gamble, Takeda, Xenoport, Abbott Pharmaceuticals, and Johnson & Johnson. He has also received research grant support from the NIH.