Preventing Recurrences of Reflux Esophagitis

Because reflux esophagitis is often a recurring condition, attention must be paid to optimizing prevention and management of these recurrences. Even maintenance therapy with a proton pump inhibitor (PPI) is associated with 11-35% recurrence rates, compared to 75-92% on placebo. Whether patients should receive maintenance therapy from the outset, or wait until recurrence(s), is not yet well-established and, to some degree, may be dependent upon economic considerations.

This analysis examines the outcomes of patients with erosive reflux esophagitis defined as at least one erosion or ulceration at the squamocolumnar junction prior to healing that is symptomatic and has healed on a PPI or H2-receptor antagonist, without evidence of concomitant precipitating or complicating factors. As a model, data from long-term trials of lansoprazole vs. placebo were used.

The least expensive and least effective strategy is to delay maintenance therapy until a second recurrence. Providing maintenance therapy from the outset is the most effective and most costly, adding $819 for each prevented recurrence (compared to a "no maintenance until a first recurrence" approach). The authors conclude that for patients with the most severe disease, maintenance therapy from the outset is the therapy of choice. For more moderate disease, waiting for a single recurrence is a preferred option that is cost-effective, unless it is ascertained that quality of life is substantially reduced in the patient with even moderate disease, in which case it is reasonable to institute maintenance from the outset.

Harris R, et al. Am J Med 1997;102: 78-88.