GERD in the Primary Care Office:
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Gastroesophageal Reflux Disease (GERD) is ubiquitous. From time to time, approximately 10-15% of the general population in the US suffers from some degree of reflux. In the primary care office, it is estimated that sufferers of reflux disease can approach 40-50% of patients seen. However, fewer than 1% of these patients are actually treated. Why is this? There are many factors for this low incidence of diagnosis and treatment of acid reflux. First is the wild variability of the severity of the disease. Many of the 40-50% have mild disease and either do not complain to their provider or, when questioned, have symptoms infrequent enough not to require therapy. Certainly there is a percentage of those who self-medicate and some who are missed because the provider does not perform an adequate review of systems. But, for those in who reflux is suspected by the physician, what is the appropriate management and therapeutic strategy for the primary care provider? "First, sort out the `high risk' patients"First it is important to identify as best as possible those patients who may be at a high-risk for having complications of reflux or of having diseases such as cancer to explain their symptoms. The key symptom to screen for is dysphagia, which means difficulty swallowing, or the sensation of food getting "caught". Malignancy must be considered to be a possibility in anyone with this complaint. Other risk factors for serious disease include having the onset of reflux symptoms after the age of 45, especially in white males, or having a significant history of alcohol intake or tobacco use. The duration of symptoms also may place a patient in a high-risk category. This was suggested by a recent report in the New England Journal of Medicine which reported that patients with weekly heartburn for greater than 5 years have a 20-fold greater risk of developing adenocarcinoma of the distal esophagus or gastric cardia compared to those without heartburn. High-risk subjects should, in most cases, be referred directly for diagnostic upper endoscopy in order to assess directly the severity of their condition and to exclude entities such as benign strictures, pre-malignant Barrett's esophagus, and malignancies. "Next, begin empiric treatment"After sorting out the high-risk patients, what is left is the majority of people who present to the primary care office with symptoms of reflux disease. For these patients it is safe and appropriate care to begin initial empiric treatment without performing diagnostic tests. Empiric therapy often has begun before the patient arrives at the primary care office since many patients have already tried various home remedies. These would include use of over-the-counter (OTC) liquid or tablet form of antacids and low-dose histamine-2 receptor antagonist (H2RA), e.g. ranitidine/Zantac, cimetadine/Tagamet, famotidine/Pepcid, and nizatidine/Axid). However, the fact that the patient is in the primary care office looking for a remedy implies that each of these avenues have failed to provide effective and/or long term relief. It might be assumed that the failure of each of these regimens may be due to insufficient time allowed on the part of the patient and that the treatment regimen would have worked given a better chance. This raises the question, should the first step be a longer trial of an OTC regimen? Probably not! "Remember, it's not all drugs"Good treatment begins with non-pharmacologic advice such as tobacco cessation, avoiding eating within two hours of lying down, elevating the head of the bed by six inches, avoiding foods which promote the acid reflux (onions, garlic, coffee, caffeine, alcohol, peppermint, spearmint), and considering a weight loss program. At this juncture the primary care physician has two available treatment options when moving beyond the OTC agents. These are to treat from the "bottom up" or to treat from the "top down". There are certainly arguments for both and each will be explored. Treating from the "bottom up" means beginning therapy with a discussion of life-style changes and initiation of an H2RA at therapeutic doses. If this fails to provide relief within a reasonable time (2-4 weeks) then the H2RA is discontinued and a Proton Pump Inhibitor (PPI) is started, again at therapeutic doses. Should this regimen fail, the dose of the PPI can be increased, especially if the symptoms are respiratory such as cough, asthma, or hoarseness. Commonly, a bed time dose of an H2RA is added to the regimen. "Step-Up" vs. "Step-Down" TreatmentWhat is the argument for the "step up"? Probably the best, and perhaps only one, is cost. The H2RA's are cheaper than the PPI's and many insurance plans limit use of PPI's to short-term therapy (four-six weeks), or only after a failed trial of a H2RA. Should this be the case, then certainly using this approach must be considered, unless the patient is willing and, perhaps more important, able to purchase a PPI. However, having said all this, if the patient is treated with therapeutic doses of an H2RA, and has significant improvement of symptoms within 2-4 weeks, this is an acceptable regimen. There is however, one caveat. H2RA's become less effective over time with chronic use. It is not unusual for the patient on chronic H2RA therapy to have a return of symptoms or to develop some new, and perhaps unrecognized, reflux symptom, often in as short a period as 3-6 months. When this occurs, a change to a PPI is not only justified, but also necessary. For insurance purposes, this can be considered a therapeutic failure. This "treatment failure" however, does not, by itself, place the patient in a high-risk category unless symptoms were, in actuality, never controlled. So, where does that leave us? Treating as "step down" implies beginning with the strongest treatment, a Proton Pump Inhibitor (PPI), to gain rapid symptom control and patient satisfaction. The "step down" method has several attributes and a significant flaw. That flaw, as pointed out above, is cost. The PPI's (of which there are currently 5 available in the US) are expensive. A month's therapy, at usual recommended doses, can cost anywhere from $45-$135 per month. Most patients and insurance companies are not inclined to pay these prices if another therapy is available at one-half to one-third the cost. However, there are several arguments that are reasonable in support of a "step down" therapeutic approach. First is the fact that most patients will have already tried and failed an H2RA, albeit at OTC dosages. Second, for patients with moderate to severe symptoms, the PPI's have been shown to have better short and long-term success, and third, there is the issue of tachyphylaxis that may occur with chronic use of H2RA's. In the long run use of a PPI as initial therapy in a low-risk patient with moderate to severe reflux symptoms is probably less expensive than an initial trial of an H2RA. This is because a PPI provides excellent, rapid relief and thereby obviates the need for office visits and diagnostic studies. In summary, the primary care provider, with no diagnostic studies and close follow-up, can safely treat the low-risk patient with moderate to severe symptoms of GERD, whether these are gastrointestinal or respiratory symptoms. Treatment should include discussion of life-style modifications and therapeutic doses of either an H2RA or a PPI with emphasis on the pros and cons of each of these. The "step down" approach is probably the therapy of choice in this patient population. Jacksonville Medicine / June/July, 2002What's New
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