Long-term treatment of gastro-oesophageal reflux disease in primary care

Abstract

Gastro-oesophageal reflux disease (GORD), characterized by heartburn and acid regurgitation, is one of the most common gastrointestinal diseases general practitioners encounter. GORD is effectively treated with acid suppressive medication (ASM), of which proton pump inhibitors (PPIs) are most commonly used. Due to high therapy satisfaction and minor side-effects, initial short-term treatment with PPIs often evolves in long-term treatment, resulting in many GORD patients chronically using ASM without evidence-based indication. Dosage reduction is promoted for budgetary reasons and to prevent unnecessary use and adverse side-effects of long-term acid suppression. Since 2000, ‘on-demand’ treatment with PPIs has been shown to be effective and safe for GORD treatment; patients only take medication when they experience symptoms, and terminate treatment once symptoms are controlled satisfactorily. Our study investigated whether long-term treated GORD patients can reduce their ASM dosage, how a dosage reduction affects symptom control and quality of life, and whether a successful transfer to on-demand treatment after long-term treatment can be predicted using patient characteristics. Primary care GORD patients chronically using ASM, without evidence-based indication for this use were investigated. The minimal effective dosage was determined in a blinded way with minimal interference by placebo-effects: Patients received two containers, one for daily use and one with rescue tablets. They were instructed to use one tablet per day from the daily container and in case of inadequate symptom control one from the rescue container. Group 1 had placebo in the daily container and PPI as rescue; these patients blindly adjusted their PPI dosage. Group 2 had a PPI in the daily container and placebo ‘rescue’. Characterization of included patients: 1. A high prevalence of overweight, furthermore overweight increases the prevalence and severity of residual symptoms under ASM treatment. 2. Infection with Helicobacter pylori reduces the PPI dosage needed for symptom control. 3. GORD patients on ASM display a population-average psychological state. However, based on the adequacy of symptom control, this apparently heterogenic group can be divided into a psychologically distressed and mentally healthy subgroup. The trial showed that dosage reduction is very well possible among chronic users of ASM; 19% of patients terminated treatment, 33% reduced their dosage to 2-6 tablets/week, and 48% sustained their daily dosage. The vast majority of patients did not report decreases in symptom control and quality of life during dosage adjustment; 24% expressed a temporal decrease. Therefore, long-term daily treatment of GORD can be switched to an on-demand regime. For physicians it would be useful to be able to predict which patients are eligible for dosage reduction. To this aid we compared patients reducing their dosage with those who did not. No clinically useful combination of patient characteristics was able to adequately predict eligibility for dosage reduction. Successful transfer of patients to an on-demand regime remains a process of trial and error, in which motivation of the patient and support by the physician will be important factors for success.