The pharmacotherapeutic management of gastroesophageal reflux disease (GERD)

ABSTRACT

Introduction

Gastroesophageal reflux disease (GERD) is a very common worldwide condition, affecting about 15–20% of the whole population, and representing a major burden for health-care systems. Because of its frequency, health physicians – family doctors as well as specialists – should be aware of the different pharmacotherapeutic approaches in managing GERD, according to disease severity.

Areas covered

Authors summarize the pharmacological management of GERD in adults, present the different pharmaceutical classes, and review the evidence on efficacy for each treatment according to the most common clinical scenarios: non-erosive gastroesophageal reflux disease (NERD), erosive esophagitis (EE), and proton-pump inhibitor (PPI) refractory GERD. They also provide an overview of treatments under development.

Expert opinion

To date, PPIs remain the most effective treatment option for both NERD and EE. However, Potassium-Competitive Acid blockers (PCAB) may be considered, with at least similar efficacy in Asian populations. Preliminary data suggest that PCABs could be superior to classic PPIs in patients with severe EE, and may also be of particular interest in the management of PPI-refractory GERD patients. Their definitive role in GERD management, however, still remains to be determined based on properly designed and conducted randomized clinical trials.

KEYWORDS:

• Gastroesophageal reflux disease
• erosive esophagitis
• refractory gastroesophageal reflux disease
• proton-pump inhibitor
• potassium-competitive acid blocker

Article highlight

• GERD is one of the most frequent conditions encountered in general practice.

• Some cases of GERD may be related to overlapping syndromes such as functional heartburn or dyspepsia.

• The main evidence-based non-pharmaceutical approaches include weight loss, elevation of the head of the bed, and avoidance of recumbency for several hours after meals; these should be attempted prior to or with pharmaceutical treatment.

• In patients with mild and/or infrequent symptoms, and in the absence of alarm symptoms/signs, antacids/alginates, histamine 2 receptor antagonist, and proton-pump inhibitors (PPIs) may all be used as first-line treatments, but PPIs should be preferred as they have a more potent efficacy.

• In erosive esophagitis, a PPI is the treatment of choice, and should be prescribed, for the time being, as initial therapy.

• There is growing evidence coming from Asia that new competitive potassium acid blockers may outperform PPIs in the healing of erosive esophagitis, and may be useful in patients refractory to PPIs. These results need to be confirmed in the Western world before their broader adoption.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

One referee declares that they have received lecture fees from Takeda, EA Pharma, AstraZeneca, and Otsuka. Peer reviewers on this manuscript have no other relevant financial relationships or otherwise to disclose.