Acid Suppression in the Management of GERD—An Appraisal of Treatment Options in Primary Care

Abstract & Commentary

Synopsis: This article promotes the use of PPIs for GERD presenting in the primary care setting as more effective and ultimately also more cost-effective than use of H2-receptor agonists.

Source: Jones R, Bytzer P. Aliment Pharmacol Ther. 2001; 15:765-772.

H2-receptor antagonists (H2RAs) continue to be widely prescribed for gastroesophageal reflux disease (GERD) despite the availability of substantially more effective proton pump inhibitors (PPIs). Primary care physicians tend to consider GERD as a relatively benign disorder due to relatively low incidence of complications or other morbidity. Symptom "control" is deemed satisfactory rather than complete abolition of symptoms. Jones and Bytzer insist that GERD can indeed be an extremely serious illness, complicated by ulceration, stricture, Barrett’s esophagus, and adenocarcinoma. This paper refers to the well known McMaster University meta-analyses that suggest a linear relationship between level of acid inhibition and healing of erosive esophagitis. They also cite many studies that support PPI use over H2RAs, including faster onset of relief and more complete relief and better maintenance of remission. There is brief discussion of the potential need for endoscopic assessment in GERD onset over age 45-55 or in the setting of any "alarm symptoms."

Data are cited for increasing use of PPIs in primary care, particularly as compared to new prescriptions for H2RAs. It was mentioned that lifestyle modifications were deemed of too low efficacy to warrant much attention by primary care practitioners for their patients. Issues related to attempted step-down therapy were raised, including the notion of therapy to half dose PPIs or perhaps to some form of "on demand" therapy with PPIs. It was concluded that the use of PPIs was preferable to initiation of H2RA therapy and that this could successfully be followed by one or another "step down" approaches.

Comment by Malcolm Robinson MD, FACP, FACG

This article, not at all surprisingly, was supported by "a grant from AstraZeneca." It is "party line" for this world leader in PPI distribution (Prilosec®, Nexium®)—and this approach to GERD therapy clearly will continue to result in huge profits for them. Most or all of the comparative studies cited were also supported by PPI-makers or their strong proponents. The enormous success of the H2RAs for many years cannot now be totally disregarded due to the emergence of an admittedly excellent new class of drugs, the PPIs. Patients who respond well to H2RA therapy need not have escalation of therapy to PPIs in every case, and I am not convinced by any broad-based data that PPIs are universally superior to H2RAs, especially in mild GERD as tends to be seen most often by primary care physicians. PPIs are unquestionably "addictive" by causing rebound acid hypersecretion after they are discontinued and perhaps otherwise. On-demand use of PPIs is extremely promising, but millions of patients have been quite satisfied with on-demand H2RA use, an unquestionably safe and inexpensive approach. Jones and Bytzer are well respected physicians in Europe, one in primary care and the other in gastroenterology. Nevertheless, I would urge readers to continue to regard their recommendations with appropriate skepticism and to use their own experience to guide them to properly individualized GERD therapy.

Malcom Robinson is Medical Director, Oklahoma Foundation for Digestive Research, Clinical Professor of Medicine at University of Oklahoma College of Medicine in Oklahoma City, and Associate Editor of Internal Medicine Alert.