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AGA releases evidence-based GERD guidelines

October 22, 2008

Gastroesophageal reflux disease (GERD) is one of the most common gastrointestinal conditions seen in GI and primary care clinics, however physicians who treat the disease primarily rely on empirical trials of medications and their own observations and experience to manage their patients. Therefore, the American Gastroenterological Association (AGA) Institute has published evidence-based guidelines for the management and treatment of suspected GERD. The guidelines, which are the first produced through AGA's innovative guideline development process, are published in Gastroenterology, the official journal of the AGA Institute.

"There are many methods physicians are using to treat their patients with GERD, without knowing which is the best one," according to John I. Allen, MD, AGAF, chair, AGA Institute Clinical Practice and Quality Management Committee. "The AGA Institute developed this medical position statement on GERD to encapsulate the major management issues leading to consultations for the treatment of the disease to help guide physicians in treating their patients."

According to the authors, high-quality clinical trials for GERD management strategies do not exist. The majority of randomized controlled clinical trials are for pharmacologic therapies for esophageal GERD syndromes, especially acute trials for healing esophagitis. Therefore, many of the highest-level evidence-based recommendations in the guideline are for the acute treatment of heartburn or esophagitis. In developing the guidelines, the authors used the Montreal consensus definition for GERD, "a condition which develops when the reflux of stomach contents causes troublesome symptoms and/or complications." Troublesome symptoms are those that adversely affect an individual's well-being.

"As we found in our research, much of the current management of patients with GERD is based on experiences from physicians, uncontrolled trials and expert opinion," according to Peter J. Kahrilas, MD, AGAF, Northwestern University's Feinberg School of Medicine and lead author of the guidelines. "We hope the development of these guidelines will help clinicians better treat patients who present with suspected GERD."

The conclusions of the technical review and medical position statement were based on the best available evidence, or in the absence of quality evidence, the expert opinions of the authors and Medical Position Panel convened to critique the technical review and structure the medical position statement. The technical review and the medical position statement together represent the guideline. The strength of the conclusions were determined using the U.S. Preventive Services Task Force grades. Grade A recommendations, which are "strongly recommended based on good evidence that it improves important health outcomes," according to the AGA Institute, include:

I. Antisecretory drugs for the treatment of patients with esophageal GERD syndromes (healing esophagitis, symptomatic relief and maintaining healing of esophagitis). In these uses, proton pump inhibitors (PPIs) are more effective than histamine receptor antagonists (H2RAs), which are more effective than placebo.
II. Long-term use of PPIs for the treatment of patients with esophagitis once they have proven clinically effective. Long-term therapy should be titrated down to the lowest effective dose based on symptom control.
III. When antireflux surgery and PPI therapy are judged to offer similar effectiveness in a patient with an esophageal GERD syndrome, PPI therapy should be recommended as initial therapy because of superior safety.
IV. When a patient with an esophageal GERD syndrome is responsive to, but intolerant of, acid suppressive therapy, antireflux surgery should be recommended as an alternative.
V. Twice-daily PPI therapy as an empirical trial for patients with suspected reflux chest pain syndrome after a cardiac etiology has been carefully considered.

Other recommendations include grade B - "recommended with fair evidence that it improves important outcomes;" grade C - "balance of benefits and harms is too close to justify a general recommendation;" grade D - recommend against, fair evidence that it is ineffective or harms outweigh benefits;" and grade insufficient - "no recommendation, insufficient evidence to recommend for or against."

To develop the guidelines, a set of 12 broad questions were identified by experts in the field to encapsulate the most common management questions faced by clinicians. To review recommendations and grades, view the AGA Medical Position Statement of the Management of Gastroesophageal Reflux Disease. The guidelines were developed through interaction among the authors, the AGA Institute, the Clinical Practice and Quality Management Committee and representatives from the AGA Institute Council.

American Gastroenterological Association