Digestive Health Express Report

Publication date: 2003-06-30

Patient-directed Therapy for Mild-to-moderate Gastroesophageal Reflux Disease

Based in part on Practice Guidelines from the American College of Gastroenterology and Recommendations from the 2002 American Gastroenterological Association Consensus Development Panel-Improving the Management of GERD: evidence-based therapeutic strategies.

This report was reviewed for medical and scientific accuracy by Mark J. Sterling, MD, Assistant Professor of Medicine, and Interim Director, Division of Gastroenterology, University of Medicine & Dentistry of New Jersey (UMDNJ)-New Jersey Medical School, Newark, New Jersey

Introduction

According to recent recommendations from the American Gastroenterological Association Consensus Development Panel,¹ the combination of antacid and H₂ receptor antagonist (H₂RA) (famotidine/calcium carbonate—Pepcid Complete) provides an incremental improvement in efficacy compared to either individual ingredient in treating the symptoms of mild-to-moderate gastroesophageal reflux disease (GERD). Importantly, these recommendations reaffirm the role of over-the-counter (OTC) acid suppressants advocated as appropriate, initial patient-directed therapy for GERD in practice guidelines from the American College of Gastroenterology.²

From the patient's perspective, the impact of GERD is considerable. Studies show that GERD has a significant impact on quality of life, affecting the patient's sleep, work, and social life. A report published in 1998 showed that among 533 adults who had a history of heartburn lasting for a minimum of 6 months, patients with GERD reported significantly worse scores on physical function and well-being, as well as emotional well-being compared with the general population.³ In fact, patients with GERD reported worse emotional well-being than patients with diabetes or hypertension. Interestingly, quality-of-life scores for the GERD patients improved rapidly with successful treatment.

For the patient with mild-to-moderate GERD, there are a variety of safe and effective OTC treatment options to provide adequate relief of heartburn associated with GERD. Such options include antacids, H₂RAs, and the combination of antacid and H₂RA. After briefly reviewing the pathophysiology and clinical features of GERD, this Digestive Health Express Report will focus on the discussion of the available OTC treatment options, their advantages and disadvantages and their use in the treatment of mild-to-moderate GERD. For the purposes of this Digestive Health Express Report, the mild-to-moderate GERD patient is defined as experiencing mild symptoms that are adequately controlled by OTC therapy in conjunction with lifestyle/dietary modifications. For those patients who do not respond satisfactorily to OTC therapy or exhibit alarm symptoms, prescription strength H₂RAs, proton pump inhibitors (PPIs) and/or endoscopic examination would be clinically appropriate measures.

Perspective

GERD is one of the most common chronic disorders of the gastrointestinal tract.⁴ A systematic review of population studies of GERD symptoms (eg, heartburn) indicated a prevalence range between 10% and 48%.⁵ The socioeconomic impact of GERD is substantial given that 61 million adults in the United States experience heartburn at least once a month with 18 million individuals taking some form of medication for indigestion at least twice weekly,⁶ resulting in annual direct costs of $9.3 billion.⁷

Pathophysiology and Clinical Features of GERD

GERD occurs when the gastroesophageal sphincter malfunctions, allowing the stomach's contents to flow up into the esophagus resulting in its hallmark symptom—heartburn. Its pathogenesis has yet to be fully elucidated, but likely involves several factors^8,9 including:

• Antireflux barrier malfunction (eg, pressure relaxation of the lower esophageal sphincter [LES])
• Esophageal clearan