ACG Updates Guidance on Proton Pump Inhibitors for GERD

Phillip O. Katz, MD, MACG

For the first time since 2013 there is new guidance for diagnosing, treating, and managing patients with gastroesophageal reflux disease (GERD).

The American College of Gastroenterology (ACG), led by Phillip O. Katz, MD, MACG, Department of Medicine, Division of Gastroenterology and Hepatology, Jay Monahan Center for Gastrointestinal Health, Weill Cornell Medicine, has issued new guidance for diagnosing, treating, and managing GERD.

Since the last update to GERD guidelines by the ACG there has been a number of advancements in surgical and endoscopic therapies for GERD.

“Our understanding of the varied presentations of GERD, enhancements in diagnostic testing, and approach to patient management have evolved,” the authors wrote.

Proton Pump Inhibitors

Oner of the main changes in recent years is closer scrutiny of proton pump inhibitors (PPI), with questions about safety and overprescribing of the treatment prevalent in research.

This research has resulted in changes in guidance for managing and treating GERD with this class of treatments.

“There is conceptual rationale for a trial of switching PPIs for patients who have not responded to one PPI,” the authors wrote. “For patients who have not responded to one PPI, more than one switch to another PPI cannot be supported.”

The guidelines now call for the lowest effective dose.

Diagnosing GERD

For diagnosing GERD, patients with classic symptoms of heartburn and regurgitation with no alarm symptoms, the recommendation is for an 8-week trial of empiric PPIs once daily prior to a meal.

If the patient responds, the new reccomendations call for discontinuing the PPIs.

Another recommendation is diagnostic endoscopies after PPI is stopped for 2-4 weeks for patients whose classic symptoms do not respond adequately to the 8-week PPI trial or in patient whose symptoms return when PPIs are discontinued.

For patients with chest pain but not heartburn and adequate evaluation to exclude heart disease, the guidelines call for the objective testing for GERD.

The authors also do not recommend using barium swallow solely as a diagnostic test and endoscopies should be the first test for evaluating patients presenting with dysphagia or other alarm symptoms like weight loss and gastrointestinal bleeding, as well as for patients with multiple risk factors for Barrett’s esophagus.

For patients with suspected but unclear GERD, and no objective evidence of GERD from the endoscopy, the guidelines call for reflux monitoring off therapy to establish the diagnosis.

Finally, the authors recommend against reflux monitoring therapy solely as a diagnostic test for GERD in patients with known endoscopic evidence of Los Angeles grade C or D reflux esophagitis or in patients with long-segment Barrett’s esophagus.

They do not recommend high-resolution manometry solely as a diagnostic test for GERD.

“There is no gold standard for the diagnosis of GERD,” the authors wrote. “Thus, the diagnosis is based on a combination of symptom presentation, endoscopic evaluation of esophageal mucosa, reflux monitoring, and response to therapeutic intervention.”

Managing The Disease

The guidelines also include new recommendations for managing the disease, including weight loss for overweight or obese patients, avoiding meals within 2-3 hours of bedtime, and avoiding tobacco products.

Other recommendations include avoiding trigger foods, elevating head of the bed, treatment of PPIs over the treatment of histamine-2-receptor antagonists for healing and maintenance of healing from
eosinophilic esophagitis, and PPI administration 30-60 minutes prior to a meal rather than bedtime.

Another new recommendations is against routine addition of medical therapies in PPI nonresponders, as well as maintenance PPI therapy indefinitely or antireflux surgery for patients with Los Angeles grade C or D esophagitis.

The authors do not recommend baclofen in the absence of objective evidence of GERD and against treatment with a prokinetic agent of any kind for GERD unless there is objective evidence of gastroparesis.

Finally, the investigators do not recommend sucralfate for GERD therapy other than during pregnancy and suggest on-demand or intermittent PPI therapy for heartburn symptom control in patients with GERD.

The guidelines, “ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease,” was published online in the American Journal of Gastroenterology.