Applied Evidence

The Evaluation and Treatment of Adults with Gastroesophageal Reflux Disease

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References

Because H2Bs are now available in generic forms, price tips the scales greatly in their favor. The average cost for PPIs is nearly 10 times that of generic H2Bs (3020-mg omeprazole tablets cost $105.55 and 60 150-mg ranitidine tablets cost $10.98 as of 11/0/00). Simplicity is a toss-up: most PPIs are dosed once daily, while H2Bs are given once or twice daily. A general approach is to start patients with GERD on a reasonable dose of H2Bs, and move on to PPIs if symptoms do not resolve in 2 to 4 weeks.25,54 Some insurance companies require documentation of H2B failure before covering the increased costs of PPIs, despite their efficacy advantage.

Surgery

For patients with chronic or recurrent GERD, surgery offers an additional treatment option. Prospective cohort studies note that open Nissen fundoplication produces an 80% to 93% success rate at 10-year follow-up. Laproscopic procedures are producing similar short-term results, but long-term data are pending.38 One randomized trial demonstrated equivalent 3-year outcomes for those undergoing Nissen fundoplication and those taking 40 mg omeprazole daily.39 Decision analysis data favor the cost effectiveness of open Nissen40 if medical treatment will be required for more than 4 years, and laproscopic procedure if medical treatment will be needed for more than 10 years.41

Prognosis

GERD may be a short-term intermittent problem or may be severe and chronic in nature. Untreated, approximately 15% of patients will have symptom relief.32 Antacids can raise that rate to an estimated 20%,31,25 while H2Bs are associated with symptom-free rates of approximately 25%.30 The best outcomes are found with PPIs, where recurrence of GERD symptoms is suppressed in 75% to 82% of patients at 1-year follow-up.33,35

Although many patients will experience recurrences, chronic medications may not be necessary. In 1 study, 677 patients with heartburn and mild esophagitis were randomized to treatment with omeprazole or ranitidine for 2 weeks. If symptoms persisted, the dose of medication was doubled. If symptoms resolved, medication was stopped. Recurrences were treated for 2 to 4 weeks at the previously effective dose. Nearly half the patients were successfully treated with intermittent medication, and nearly 40% of initial responders required no further treatment.42

GERD is associated with esophageal strictures, Barrett esophagus (metaplasia of the distal esophageal columnar cells, thought to be a precursor of dysplasia and cancer) and adenocarcinoma. Limited data are available for the actual incidence of stricture in GERD patients. One retrospective cohort study of patients discharged from veterans’ administration hospitals found that 8.4% of patients with GERD had strictures, and the association between esophageal ulcers and stricture was significant.43 This study likely suffered from significant selection bias, however, and the rate in primary care practice is almost certainly much lower. Barrett was noted in 11.6% of 662 patients with GERD referred from general practice settings for endoscopy.44 Again, though, patients with GERD referred for endoscopy are likely to have more severe disease, and a recent meta-analysis suggests that the actual risk of Barrett in unselected patients is closer to 3% to 4%.45 A longer duration of symptoms was associated with an increase risk. Patients with Barrett esophagus; negative, low-grade, or indefinite dysplasia; and neither aneuploidy or increased 4N on flow cytometry are at very low risk of esophageal cancer (<2% over 5 years). Only approximately 4% of patients with Barrett go on to develop esophageal cancer.46

In a well-conducted case control study in Sweden, reflux symptoms were associated with a 7- to 10-fold increase in the risk of esophageal adenocarcinoma. A dose-response risk was noted for symptom frequency, severity, and duration.47 However, because adenocarcinoma of the esophagus is so rare, the authors note that a family physician would need to perform endoscopy on more than 1400 men older than 40 years who have severe GERD symptoms to identify 1 case of cancer. Further, there are no data to suggest that treating GERD will reduce the likelihood of these more serious sequelae.

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