Clinicians, particularly, non-GI physicians, face several challenges in treating patients with refractory reflux-like symptoms or refractory GERD.


David Armstrong, MA, MB, BChir, FRCP(UK), FRCPC, FACG, AGAF

David Armstrong, MA, MB, BChir, FRCP(UK), FRCPC, FACG, AGAF
Douglas Family Chair in Nutrition Research
Farncombe Family Digestive Health Research Institute &
Division of Gastroenterology
McMaster University Medical Centre

For many patients with gastroesophageal reflux disease (GERD), proton pump inhibitors (PPIs) remain the treatment of choice, according to David Armstrong, MA, MB, BChir, FRCP (UK), FRCPC, FACG, AGAF, and colleagues. “However, despite PPI therapy, many patients with GERD continue to be symptomatic,” they write. “There is no standardized definition of refractory GERD (rGERD) in terms of symptom frequency and severity or the proportion of patients who have persistent symptoms despite treatment with once- or twice-weekly PPI. However, persistent reflux symptoms have a substantial impact on patient QOL.”

For a study published in Neurogastroenterology & Motility, Dr. Armstrong and team qualitatively evaluated clinicians’ approaches toward the management of refractory reflux symptoms and rGERD. Clinicians (N=113) in the study completed a 17-question online survey for an International Working Group for the Classification of Oesophagitis (IWGCO) steering committee.


Functional Heartburn Most Common Reason for Incomplete Response to PPIs

Of total clinicians who responded to the survey, 70% were gastrointestinal specialists (GIs), 20% were primary care physicians, and 10% practiced in other specialties. “Functional heartburn was considered the most common reason for an incomplete response to PPI therapy (82%), followed by stress/anxiety (69%),” the study authors write “More GIs identified esophageal hypersensitivity as a cause, while more non-GIs identified esophageal dysmotility and non-reflux-related esophageal conditions.”

Most clinicians (69.9%) responded that for initial treatment, they would order at least one investigation for a fully compliant patient with persistent, but less frequent and less severe, heartburn, or regurgitation despite 8 weeks of PPI once daily plus 8 weeks of PPI twice daily (partial response; Table). “This rose to 87.6% for patients with no symptom improvement (non-response),” Dr. Armstrong, et al. said. “For non-responders, almost all GIs (92.4%) would order investigations but nearly one-quarter of non-GIs (23.8%) would not, being more likely to add supplemental therapies or consider surgery.”

Supplemental treatment for patients with partial response was recommended by 72% of clinicians, whereas for patients with non-response, only 58% of clinicians endorsed it. Overall, the most popular treatment choice was antacid/alginate. However, non-GIs were more prone to recommend a prokinetic than were GIs (47.8% vs 24.1%). The survey indicated that “approximately 40% of clinicians would switch PPIs in patients with partial response, but only 29% would do so in non-responders,” the study team notes, adding that preferences for long-term treatment varied widely.


Clear Evidenced-Based Approach Needed for Diagnosis & Treatment

Upper endoscopy was the most prevalent procedure included in any initial examination for patients with a partial or non-response to PPI therapy, according to the survey. “The choice of esophageal manometry and pH monitoring was more variable, with no clear preference for whether pH monitoring should be conducted on, or off, PPI therapy,” the study authors write.

Based on the results of their survey, Dr. Armstrong and colleagues concur that a need exists for a clear evidenced-based approach to the diagnosis and treatment of continual symptoms in patient with refractory reflux-like symptoms and rGERD despite PPI therapy. “We also need wider dissemination of available guidance to clinicians,” they add. “The wide variability of responses illustrates gaps in defining PPI non-response, most appropriate diagnostic criteria and approaches, and appropriate optimal treatment strategies for refractory reflux-like symptoms and rGERD.”