Medical therapy for gastroesophageal reflux disease

Antireflux surgery. Indications, preoperative evaluation, and outcome

Gastroesophageal reflux disease (GERD) is an extremely common disorder. Many patients require lifelong medical therapy for symptom control. In patients being considered for antireflux surgery, thorough evaluation is required. Laparoscopic antireflux surgery is a safe and effective method of treating patients who have severe, refractory, or complicated GERD. Excellent long-term results are obtained with minimal morbidity, freeing the patient from the burden of chronic medical therapy.

Prevention of recurrences of erosive reflux esophagitis: a cost-effectiveness analysis of maintenance proton pump inhibition

PURPOSE

To determine the cost-effectiveness of three management strategies for healed erosive reflux esophagitis: maintenance therapy with a proton pump inhibitor (PPI) from the outset; no maintenance therapy unless a patient's symptoms recur once over a year; and no maintenance therapy unless a patient's symptoms recur twice over a year.

MATERIALS AND METHODS

Decision analysis using data from randomized trials of lansoprazole, case series, and expert opinion.

RESULTS

For patients with grade 4 esophagitis, maintenance from the outset is the most efficient approach. For all other patients, providing maintenance PPI after a patient experiences two recurrences is the least costly but least effective approach. The other two approaches prevent more recurrences: waiting to initiate maintenance therapy until symptoms recur once requires an additional $73 for each recurrence prevented whereas maintenance PPI from the outset requires an additional $819 for each recurrence prevented. Maintenance therapy from the outset is cost effective if symptoms of esophagitis cause a 22% or greater decrement in quality of life (using $50,000 per quality-adjusted life year gained as a cost-effectiveness definition). However, withholding maintenance until the time of a first recurrence is cost effective if symptoms cause a 2% or greater decrement in quality of life.

CONCLUSION

For grades 2 and 3 esophagitis, providing maintenance therapy after a patient experiences a further recurrence is a preferred option that appears cost-effective across a wide array of assumptions. Maintenance therapy from the outset, however, appears cost-effective only for those patients who report a significant decline in quality of life associated with esophagitis or for those patients with baseline grade 4 esophagitis.

Gastroesophageal reflux disease. The long and the short of therapeutic options

Gastroesophageal reflux disease (GERD) is a common and treatable condition. Initial therapy includes lifestyle modifications, avoidance of certain medications, and use of antacids, alginic acid preparations, and over-the-counter histamine2 (H2) receptor antagonists. Escalation of therapy for acute disease relies primarily on H2 receptor antagonists given in conventional dosages. Although H2 receptor antagonists remain the cornerstone of therapy, sucralfate and promotility agents, especially cisapride, may offer alternatives. Most cases of GERD that are resistant to these therapies can be reliably healed with proton pump inhibitors (PPIs). Patients whose GERD is healed with one of the aforementioned agents often relapse unless they receive further therapy. For patients with mild disease, H2 receptor antagonists, cisapride, or a combination of the two may prevent recurrent symptoms. In severe disease, PPIs are the agents of first choice, but concerns about the safety of long-term use must be considered. In selected patients, surgery offers an option for long-term control of GERD. With present surgical techniques, symptom relief can be obtained with little risk of complications.

Medical Therapy of GERD: current state of the art

A proton pump inhibitor is the most cost-effective choice for severe disease and, in low doses, for moderate disease. Patients with mild disease and infrequent relapses can be managed with a H2-receptor antagonist, an antacid, or cisapride.

Respiratory complications of gastroesophageal reflux disease

There is a relationship between gastroesophageal reflux disease and certain respiratory symptoms and findings. Among these are cough, laryngitis, and wheezing dyspnea. The pathophysiology of these conditions can vary from actual aspiration of gastric content to esophageal mucosal inflammation with the respiratory symptoms induced by a vagally mediated reflex mechanism.

The diagnosis and management of gastroesophageal reflux disease

GERD is a common clinical problem. Generally, its clinical presentation and management are straightforward. Greater awareness of the numerous extraesophageal manifestations of the disease aids patients and physicians in appropriate recognition and treatment. Medical therapy is effective in the majority of cases but often requires long-term medication for acceptable symptom control. A small, but significant proportion of patients presents with or develops complications of GERD, most importantly Barrett's esophagus. Although the logistics of long-term surveillance of persons with Barrett's esophagus is unclear, the association of this metaplastic change with esophageal adenocarcinoma underscores the importance of regular follow-up.

Laparoscopic Nissen fundoplication is a satisfactory alternative to long-term omeprazole therapy

A total of 168 patients with proven gastro-oesophageal reflux disease (GORD) receiving long-term medical therapy underwent laparoscopic Nissen fundoplication. The operation was converted to open fundoplication in four patients. All patients reported complete (92.3 per cent) or partial (7.7 per cent) relief of reflux symptoms 1 month after surgery. There were no associated deaths and the perioperative complication rate was 8.9 per cent. The mean(s.e.m.) length of operating time was 69.9(2.4) min and mean(s.e.m.) hospital stay 2.7(0.1) days. Symptom score assessment, 24-h oesophageal pH recording and lower oesophageal sphincter pressure showed significant (P < 0.0001) improvement 6 months after surgery in 85 evaluable patients. Before operation 37.5 per cent of the patients were considered symptomatically controlled on omeprazole and had excellent symptom control after surgery. This initial experience suggests that laparoscopic Nissen fundoplication is a safe and effective treatment for patients with GORD requiring long-term medication.

Pharmacological management of gastro-oesophageal reflux disease

Gastro-oesophageal reflux disease (GORD) ranges from episodic symptomatic reflux without oesophagitis to severe oesophageal mucosal damage, such as Barrett's metaplasia or peptic stricture. The multifactorial pathogenesis of GORD prevents medical cure of the disease. GORD is a chronic disease with a high tendency to relapse, requiring a long term treatment strategy in practically all patients. Complete healing of all mucosal lesions is not necessarily the aim of treatment in all patients. In milder forms of reflux disease, symptom relief is the most important goal. Many patients with mild GORD do well on symptomatic self-care with antacids and/or alginate. In addition, lifestyle changes should be advised to all patients: these improve symptoms and enhance the efficacy of therapy. In the acute treatment of GORD the prokinetic drug cisapride has been shown to be effective in relieving symptoms and healing grade I to II oesophagitis. Cisapride decreases symptomatic and endoscopic relapse in patients with mild GORD. Histamine H2-receptor antagonists are effective in relieving reflux symptoms in about 50% of patients, but with regard to healing, H2-antagonists appear to be mainly effective in grades I and II and not in higher grades of oesophagitis. Maintenance treatment with H2-antagonists is mainly symptomatically effective in patients with mild GORD. Proton pump inhibitors (PPIs) provide significantly higher healing rates of reflux oesophagitis than H2-antagonists, even in the more severe cases of oesophagitis and Barrett's ulcers. PPIs are also effective in patients with oesophagitis refractory to treatment with H2-antagonists. PPIs have become the drugs of first choice in healing of all patients with more severe forms of reflux oesophagitis, and increasingly also for patients with milder forms of oesophagitis, certainly those who fail to respond to other drugs. In maintenance treatment of GORD, PPIs are the most effective drugs, offering the possibility of keeping nearly all patients in remission with adjusted doses. Current patient data of up to 5 years indicate the safety of this strategy for this period, but the exact consequences of strong acid inhibition over a longer period still have to be clarified. At present, all but a few patients with GORD can be managed adequately by medical therapy.

Review article: drug therapy for reflux oesophagitis

Gastro-oesophageal reflux disease is a common disorder and symptoms can be mild to severe. Management of the disease should be individualized. Life-style changes are important for all patients. Drug therapy is often necessary but only very few patients with severe disease need surgical treatment. The purpose of this article is to focus on drug therapy and to review the clinical trials of all the drugs used for gastro-oesophageal reflux disease. Thereafter, judged solely on the data derived from these trials, a practical approach to the management of gastro-oesophageal reflux disease is suggested.

Cisapride: a gastrointestinal prokinetic drug

OBJECTIVE

To summarize the pharmacology, pharmacokinetics, efficacy, and safety of cisapride, and to evaluate its potential therapeutic role.

DATA SOURCES

A computerized search of the MEDLINE database was used to identify English-language publications of cisapride data in humans. The MEDLINE search was supplemented by review article bibliographies. There was no attempt to limit the search to a specific gastrointestinal motility disorder.

STUDY SELECTION

The MEDLINE search alone identified 165 citations. Because of the volume of available human cisapride data, the focus of the efficacy section is on complete published reports of controlled clinical studies. Abstracts and uncontrolled data are discussed only when other information is unavailable to address important aspects.

DATA EXTRACTION

Information regarding study design, study population, results, and safety was recorded from each publication. The placebo response to gastrointestinal complaints in patients with motility disorders is high. Therefore, objective evidence of improvement was emphasized when documentation was available.

DATA SYNTHESIS

Cisapride stimulates the motility of smooth muscle lining the esophagus, stomach, small intestine, and colon, and increases the tone of gut sphincters in vitro and in vivo. In controlled investigations, cisapride was superior to placebo in relieving symptoms associated with reflux esophagitis, nonulcer dyspepsia, and gastroparesis. Similar symptom and healing effects were observed with cisapride and histamine (H)2-antagonists in reflux esophagitis. Cisapride was either equal to or superior to metoclopramide in relieving reflux symptoms. However, metoclopramide was associated with significantly more central nervous system adverse effects. Cisapride was well tolerated, with adverse effects limited primarily to the gastrointestinal tract.

CONCLUSIONS

Cisapride represents an attractive alternative to metoclopramide for the treatment of a variety of motility disorders. Because it addresses a primary underlying cause of reflux esophagitis, cisapride may also prove to be an effective alternative to acid suppressants in the management of this disorder.