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Gastroesophageal Reflux Disease

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Content Update

July 7, 2019

Updated Recommendation on the Long-Term Safety of Proton Pump Inhibitors (PPIs): In 2017, the American Gastroenterological Association (AGA) released best practice recommendations evaluating the risks and benefits of long-term proton pump inhibitor (PPI) therapy based on observational studies, including chronic kidney disease, dementia, bone fracture, myocardial infarction, Clostridioides difficile infection, other enteric infections, pneumonia, micronutrient deficiencies, and gastrointestinal cancer. This report stated that the risk of C. difficile infection was “modest” compared with traditional risk factors such as antibiotics. In the first and largest prospective, randomized trial examining the long-term safety of PPIs (specifically pantoprazole) published in 2019, after a median of three years of use, PPIs did not increase the risk of any of these adverse effects except for non-Clostridioides difficile enteric infections. The authors concluded that PPI therapy is safe for up to 3 years and that limiting prescription of PPI therapy because of concerns of long-term harm is not warranted.

LEARNING OBJECTIVES

LEARNING OBJECTIVES

Upon completion of the chapter, the reader will be able to:

  1. Explain the underlying causes of gastroesophageal reflux disease (GERD).

  2. Understand the difference between typical, atypical, and alarm symptoms.

  3. Determine when diagnostic tests should be recommended based on the clinical presentation.

  4. Identify the desired therapeutic outcomes for patients with GERD.

  5. Recommend appropriate nonpharmacologic and pharmacologic interventions for patients with GERD.

  6. Educate patients on appropriate lifestyle modifications and drug therapy issues including adherence, adverse effects, and drug interactions.

  7. Formulate a monitoring plan to assess the effectiveness and safety of pharmacotherapy for GERD.

INTRODUCTION

Gastroesophageal reflux is the retrograde, effortless movement of stomach contents into the esophagus. When troublesome symptoms or mucosal damage occurs as a result of this process, this is defined as gastroesophageal reflux disease (GERD).1,2 Treatment is usually initiated based on symptom presentation rather than laboratory tests or invasive monitoring and consists of various lifestyle interventions and pharmacotherapy. Lack of response to empiric therapies may require further evaluation to identify potential underlying complicating conditions.1,3

EPIDEMIOLOGY AND ETIOLOGY

GERD is one of the most common gastrointestinal conditions. Up to 40% of Americans report intermittent GERD symptoms, with 10% to 20% of the US population reporting at least weekly symptoms.1 GERD symptoms can result in morbidity and decreased work productivity. The incidence of erosive esophagitis and Barrett esophagus increases with age, especially in Caucasian men over 50 years of age with symptoms for more than 10 years.3,4

The precise etiology of GERD is difficult to determine in most patients. Increased intraabdominal pressure or decreased lower esophageal sphincter (LES) tone may allow gastric refluxate to enter the esophagus ...

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