Beyond PPIs: What is the Best Approach to Managing Refractory GERD?

The most pressing in managing gastroesophageal reflux disease (GERD) today is finding an effective approach to relieving refractory symptoms in patients on proton pump inhibitors, according to a specialist on the condition who spoke this week at a joint conference of the American Gastroenterological Association and the American Society for Gastrointestinal Endoscopy in Coronado, California.

A common condition, GERD is difficult to define but constitutes about 17 percent of all digestive disease diagnoses, said John Pandolfino, MD, professor of medicine, Gastroenterology and Hepatology, at the Feinberg School of Medicine at Northwestern University in Chicago. Proton pump inhibitors (PPI), which work by suppressing the production of stomach acids, are often prescribed to treat the condition. Although PPIs are considered to be effective treatment for GERD, 30-50% of patients complain that the medications do not adequately control their symptoms.

Almost everyone takes or has taken PPIs, said Pandolfino. However, some patients treated with PPI have refractory symptoms that cannot be controlled even with aggressive treatment. “The main clinical issue that we need to deal with in 2013 is refractory symptoms in patients on PPIs,” Pandolfino said.

The definition of refractory GERD is complex and confusing and patients who experience it are often referred to as PPI non-responders because they don’t improve with PPI treatment, said Pandolfino. But many patients who don’t respond to PPI treatment actually don’t have reflux; they may have other conditions, such as functional heartburn, that mimic but are not GERD, he said.

The key to managing refractory GERD is to determine whether a patient is actually suffering from symptoms related to it or whether another diagnosis is possible. There is no “gold standard” for diagnosis among this patient population, which further frustrates efforts in patient management and research, according to Pandolfino.

“The whole idea of doing empiric treatment with PPI and getting a symptom evaluation really has left us way short of where we need to be,” he said.

The problem according to Pandolfino is that a standard PPI dosage is not well defined and varies from one physician to another. In his practice, he prescribes standard doses for two to four weeks and looks for a symptom response.

“You should see a symptom response that soon,” said Pandolfino. “If the patients don’t get better, I query them on their medication compliance, because 50 percent of people who take PPIs don’t take them appropriately.”

Those patients may need counseling and a reminder that the best way to take PPI medicine is before a meal because it works better synergistically with food, said Pandolfino.

If patients fail to respond after a second treatment, Pandolfino escalates their reflux therapy. Although there is no FDA approval for twice daily dosing, doctors frequently try that route if standard treatment fails, said Pandolfino.

If treatment fails and patients cannot get lasting relief of symptoms, it may be time to have them stop PPI medication and undergo reflux testing such as esophageal pH monitoring to check for acid in the esophagus. The answer may require more than one test, he said. “These are complicated patients,” said Pandolfino. “We shouldn’t feel bad about ourselves because we have to do two tests.”