An economic appraisal reviewing different treatment modalities and their cost-effectiveness. Proton pump inhibitors are considered more cost effective than H2 receptor antagonists
- disease. Alim Pharmacol Ther
Patient population: Adults Objective: To implement a cost-effective and evidence-based strategy for the diagnosis and treatment of gastroesophageal reflux disease (GERD). Key Points: Diagnosis History. If classic symptoms of heartburn and acid regurgitation dominate a patient’s history, then they can help establish the diagnosis of GERD with sufficiently high specificity, although sensitivity remains low compared to 24-hour pH monitoring. The presence of atypical symptoms (Table 1), although common, cannot sufficiently support the clinical diagnosis of GERD [B*]. Testing. No gold standard exists for the diagnosis of GERD [A*]. Although pH probe is accepted as the standard with a sensitivity of 85% and specificity of 95%, false positives and false negatives still exist [II B*]. Endoscopy lacks sensitivity in determining pathologic reflux but can identify complications (e.g. strictures, erosive esophagitis, Barrett’s esophagus) [I A]. Barium radiography has limited usefulness in the diagnosis of GERD and is not recommended [III B*]. Therapeutic trial. An empiric trial of anti-secretory therapy (AST) can identify patients with GERD who lack alarm/warning symptoms (Table 2) [I A*] and may be helpful in the evaluation of those with atypical manifestations of GERD, specifically non-cardiac chest pain (NCCP) [II B*]. Treatment Lifestyle modifications. Lifestyle modifications (Table 3) should be recommended throughout the treatment of GERD [II B], yet there is evidence-based data to support only weight loss and avoiding recumbency several hours after meals [II C*]. Pharmacologic treatment. H2-receptor antagonists (H2RAs), proton pump inhibitors (PPIs), and prokinetics have proven efficacy in the treatment of GERD [I A*]. Prokinetics are as effective as H2RAs but are currently unavailable [III A*]. Carafate and antacids are ineffective [III A*], but may be used as supplemental acid-neutralizing agents for certain patients with GERD [II D*]. • Non-erosive reflux disease (NERD): Step-up (H2RA then as followed by a PPI if no improvement) and step-down (PPI then followed by the lowest dose of acid suppression) therapy are equally effective for acute treatment and maintenance [I B*]. On demand (patient-directed) therapy is the most cost-effective strategy [I B]. • Erosive esophagitis: Initial PPI therapy is the treatment of choice for acute and maintenance therapy for patients with documented erosive esophagitis [I A*]. • Take PPI’s 30-60 minutes prior to breakfast (and dinner if BID) to optimize effectiveness [I B*]. Use generic and OTC formulations exclusively, eliminating need for prior authorizations. • Patients should not be left on AST without re-evaluation of symptoms to minimize cost and the potential adverse events from medications [I B]. Surgery. Anti-reflux surgery is an alternative modality in GERD treatment for patients with chronic reflux and recalcitrant symptoms [II A*], yet has a significant complication rate (10-20%). Resumption of pre-operative medication treatment is common (> 50%) and may increase over time. Other endoscopic modalities. While less invasive and with fewer complications, they have lower response rates than anti-reflux surgery [II C*], and have not been shown to reduce acid exposure. Follow up Symptoms unchanged. If symptoms remain unchanged in a patient with a prior normal endoscopy, repeating endoscopy has no benefit and is not recommended [III C*]. Warning signs. Patients with warning/alarm signs and symptoms suggesting complications from GERD (Table 2) should be referred to a GERD specialist. Risk for complications. Further diagnostic testing (e.g., EGD [esophagogastroduodenoscopy], pH monitoring) should be considered in patients who do not respond to acid suppression therapy [I C*] and in patients with a chronic history of GERD who are at risk for complications. Chronic reflux has been suspected to play a major role in the development of Barrett’s esophagus, yet it is unknown if outcomes can be improved through surveillance and medical treatment [D*].