TY - JOUR
T1 - Management options for patients with GERD and persistent symptoms on proton pump inhibitors
T2 - recommendations from an expert panel
AU - Yadlapati, Rena
AU - Vaezi, Michael F.
AU - Vela, Marcelo F.
AU - Spechler, Stuart J.
AU - Shaheen, Nicholas J.
AU - Richter, Joel
AU - Lacy, Brian E.
AU - Katzka, David
AU - Katz, Philip O.
AU - Kahrilas, Peter J.
AU - Gyawali, C. Prakash
AU - Gerson, Lauren
AU - Fass, Ronnie
AU - Castell, Donald O.
AU - Craft, Jenna
AU - Hillman, Luke
AU - Pandolfino, John E.
N1 - Funding Information:
(RY, MFV, JC, JEP); Collecting and interpreting data (RY, MFV, MFV, SJS, NJS, JR, BEL, DK, POK, PJK, CPG, LG, RF, DOC, JC, LH, JEP); Drafting the manuscript (RY, MFV, MFV, SJS, NJS, JR, BEL, DK, POK, PJK, CPG, RF, DOC, JC, LH JEP); and Approving final manuscript draft (RY, MFV, MFV, SJS, NJS, JR, BEL, DK, POK, PJK, CPG, RF, DOC, JC, LH, JEP). Financial support: RY and JEP supported by NIH R01 DK092217 (JEP). Potential competing interests: MFV, MFV, SJS, JR, DK, POK, PJK, CPG, LG, RF, DOC, JC, LH: None. RY: Consultant for Ironwood. CPG: Research: Medtronic; Consultant: Ironwood, Torax, Quintiles; and Teaching: Medtronic, Sandhill. NJS: Research funding: Boston Scientific, CSA Medical, C2 Therapeutics, CDx Medical, Interpace Diagnostics, and Medtronic. Consultant for Shire and Cook Medical. BEL: Scientific advisory board member for Ironwood, Salix. JEP: Consultant for Crospon, Ironwood, Torax, Astra Zeneca, Takeda, Impleo, Medtronic, and Sandhill.
Publisher Copyright:
© 2018, American College of Gastroenterology.
PY - 2018/7/1
Y1 - 2018/7/1
N2 - Background: The aim of this study was to assess expert gastroenterologists’ opinion on treatment for distinct gastroesophageal reflux disease (GERD) profiles characterized by proton pump inhibitor (PPI) unresponsive symptoms. Methods: Fourteen esophagologists applied the RAND/UCLA Appropriateness Method to hypothetical scenarios with previously demonstrated GERD (positive pH-metry or endoscopy) and persistent symptoms despite double-dose PPI therapy undergoing pH-impedance monitoring on therapy. A priori thresholds included: esophageal acid exposure (EAE) time >6.0%; symptom-reflux association: symptom index >50% and symptom association probability >95%; >80 reflux events; large hiatal hernia: >3 cm. Primary outcomes were appropriateness of four invasive procedures (laparoscopic fundoplication, magnetic sphincter augmentation, transoral incisionless fundoplication, radiofrequency energy delivery) and preference for pharmacologic/behavioral therapy. Results: Laparoscopic fundoplication was deemed appropriate for elevated EAE, and moderately appropriate for positive symptom-reflux association for regurgitation and a large hiatal hernia with normal EAE. Magnetic sphincter augmentation was deemed moderately appropriate for elevated EAE without a large hiatal hernia. Transoral incisionless fundoplication and radiofrequency energy delivery were not judged appropriate in any scenario. Preference for non-invasive options was as follows: H2RA for elevated EAE, transient lower esophageal sphincter relaxation inhibitors for elevated reflux episodes, and neuromodulation/behavioral therapy for positive symptom-reflux association. Conclusion: For treatment of PPI unresponsive symptoms in proven GERD, expert esophagologists recommend invasive therapy only in the presence of abnormal reflux burden, with or without hiatal hernia, or regurgitation with positive symptom-reflux association and a large hiatus hernia. Non-invasive pharmacologic or behavioral therapies are preferred for all other scenarios.
AB - Background: The aim of this study was to assess expert gastroenterologists’ opinion on treatment for distinct gastroesophageal reflux disease (GERD) profiles characterized by proton pump inhibitor (PPI) unresponsive symptoms. Methods: Fourteen esophagologists applied the RAND/UCLA Appropriateness Method to hypothetical scenarios with previously demonstrated GERD (positive pH-metry or endoscopy) and persistent symptoms despite double-dose PPI therapy undergoing pH-impedance monitoring on therapy. A priori thresholds included: esophageal acid exposure (EAE) time >6.0%; symptom-reflux association: symptom index >50% and symptom association probability >95%; >80 reflux events; large hiatal hernia: >3 cm. Primary outcomes were appropriateness of four invasive procedures (laparoscopic fundoplication, magnetic sphincter augmentation, transoral incisionless fundoplication, radiofrequency energy delivery) and preference for pharmacologic/behavioral therapy. Results: Laparoscopic fundoplication was deemed appropriate for elevated EAE, and moderately appropriate for positive symptom-reflux association for regurgitation and a large hiatal hernia with normal EAE. Magnetic sphincter augmentation was deemed moderately appropriate for elevated EAE without a large hiatal hernia. Transoral incisionless fundoplication and radiofrequency energy delivery were not judged appropriate in any scenario. Preference for non-invasive options was as follows: H2RA for elevated EAE, transient lower esophageal sphincter relaxation inhibitors for elevated reflux episodes, and neuromodulation/behavioral therapy for positive symptom-reflux association. Conclusion: For treatment of PPI unresponsive symptoms in proven GERD, expert esophagologists recommend invasive therapy only in the presence of abnormal reflux burden, with or without hiatal hernia, or regurgitation with positive symptom-reflux association and a large hiatus hernia. Non-invasive pharmacologic or behavioral therapies are preferred for all other scenarios.
UR - https://www.scopus.com/pages/publications/85045834286
U2 - 10.1038/s41395-018-0045-4
DO - 10.1038/s41395-018-0045-4
M3 - Article
C2 - 29686276
AN - SCOPUS:85045834286
SN - 0002-9270
VL - 113
SP - 980
EP - 986
JO - American Journal of Gastroenterology
JF - American Journal of Gastroenterology
IS - 7
ER -