ACG guideline updates recommendations on diagnosis, management of GERD

Proton-pump inhibitors remain a standard treatment for gastroesophageal reflux disease (GERD) despite increased scrutiny of side effects, although new treatments are emerging, the guideline from the American College of Gastroenterology (ACG) stated.

The American College of Gastroenterology recently released an updated guideline on diagnosis and management of gastroesophageal reflux disease (GERD).

The evidence-based recommendations, which were published Nov. 22 by the American Journal of Gastroenterology, update the 2013 guideline on this topic and provide practical guidance on pharmacologic, lifestyle, surgical, and endoscopic management.

Potential new drugs for GERD, such as potassium-competitive acid blockers, are in phase 3 trials, but proton-pump inhibitors (PPIs) remain a cornerstone of treatment, the guideline said. Patients with classic GERD symptoms of heartburn and regurgitation who have no alarm symptoms can undergo an eight-week trial of empiric PPIs once daily before a meal (moderate-quality evidence/strong recommendation), the guideline said. Patients whose symptoms respond can attempt to stop PPIs (low-quality evidence/conditional recommendation). A key point in the guideline advised physicians how to address long-term use with patients, noting that the drugs' effectiveness, benefits, and risks should be discussed.

For GERD management, the guideline recommended weight loss in overweight and obese patients to improve GERD symptoms (moderate-quality evidence/strong recommendation). Avoiding meals within two to three hours of bedtime, tobacco products/smoking, and “trigger foods” for GERD symptom control all received conditional recommendations based on low-quality evidence, as did elevating the head of the bed for nighttime GERD symptoms.

The guideline recommended PPIs over histamine-2 receptor antagonists for treatment (high-quality evidence/strong recommendation) and maintenance of healing (moderate-quality evidence/strong recommendation) for erosive esophagitis. PPIs should be taken 30 to 60 minutes before a meal rather than at bedtime for symptom control, the guideline said (moderate-quality evidence/strong recommendation).

For refractory GERD, the guideline recommended optimizing PPI therapy as the first step in management (moderate-quality evidence/strong recommendation). Antireflux surgery should be done by an experienced surgeon and is an option for long-term treatment of patients with objective evidence of GERD. Those who have severe reflux esophagitis (Los Angeles grade C or D), large hiatal hernias, and/or persistent, troublesome GERD symptoms are likely to benefit most from surgery, the guideline said (moderate-quality evidence/strong recommendation). Magnetic sphincter augmentation can be considered as an alternative to laparoscopic fundoplication for patients with regurgitation in whom medical management fails (moderate-quality evidence/strong recommendation).

The guideline provided algorithms that offer an overall approach to diagnosis and management of GERD's major presentations, the authors said, noting that they attempted to address all of the key issues in PPI management and adverse events to provide a comprehensive resource.

“We expect that new diagnostic tools and treatments will be developed and those that we have will be further refined. … Future research with advanced endoscopic techniques, data on long-term efficacy of surgical intervention, and advances in artificial intelligence and basic science will almost certainly change the way we manage GERD going forward,” the authors wrote.