No One Treatment for Acid Reflux Clearly Better Than Another: Study
THURSDAY, Sept. 29 -- Medications are effective for most patients with acid reflux disease, but some surgical options may be just as effective, according to a review of studies on current treatments for this common condition.
Acid reflux disease, also known as gastroesophageal reflux disease or GERD, occurs when the contents of the stomach -- including burning acid -- chronically spill up into the esophagus, causing heartburn and other symptoms such as a persistent cough, laryngitis and asthma.
Acid reflux disease may afflict as many as 4 percent of Americans, resulting not only in a sometimes significant financial drain but also more serious long-term consequences such as esophageal cancer, according to background information in the report released Sept. 23 by the U.S. Agency for Healthcare Research & Quality (AHRQ), part of the U.S. Department of Health & Human Services.
Obesity, which is widespread globally and growing, probably ups the risk for GERD.
The authors of the report looked at three categories of treatment: medications; a type of surgery known as fundoplication, often done laparoscopically; and fundoplication done using an endoscope, or lighted tube, to guide surgeons.
Two classes of drugs are the mainstay of treatment for GERD: proton pump inhibitors (PPIs) such as Nexium (esomeprazole), Prevacid (lansoprazole) and Prilosec (omeprazole), and histamine-2 receptor antagonists (H2RAs), such as Tagamet (cimetidine) and Pepcid (famotidine).
PPIs tended to be the more effective of the two drugs but there wasn't much of a difference between different PPIs or dosages, said Dr. Elisabeth Kato, a medical officer at AHRQ.
And generally side effects weren't all that serious, although use of PPIs has been associated with an increased risk of some bacterial infections and fractures.
Fundoplication is "surgery to wrap the upper portion of the stomach around the esophagus," explained Kato. "The idea here is to provide a bit of a barrier to stop the stomach acid from washing back up into esophagus."
There were fewer studies on fundoplication than on drugs but the studies that were done "suggested that for some patients, surgery did help control some of their symptoms a little bit better but in general didn't allow them to completely stop taking medications," Kato said.
There were also more severe side effects, including infections and difficulty swallowing.
There was much less information on a third treatment, which is essentially fundoplication done using an endoscope. There weren't enough data to come to any conclusions about its effectiveness, Kato said.
"I would say endoscopic therapies for GERD are really minimally utilized at this point in time ... and the data would suggest that, at best, it's fair-to-moderately effective," added Dr. Thomas Watson, chief of thoracic surgery at the University of Rochester Medical Center in New York.
Nor was it clear to the authors of the report which patients would do better with which type of treatment, which treatment might better prevent long-term complications such as cancer, or which treatment was safer over the long haul.
"There are no clear-cut guidelines," Watson said. "It comes down to the severity of the disease, the age of the patient, their desires, their willingness or unwillingness to stay on long-term therapy, as well as their willingness or unwillingness to undergo surgery."
Added Dr. Benjamin Havemann, an assistant professor of internal medicine at Texas A & M Health Science Center College of Medicine: "This [study] does make the case for patients making an educated decision in partnership with their treating gastroenterologist and surgeon. What we're left with is two compelling treatments for GERD [fundoplication and medication], which have similar efficacy. In the end, in the absence of a gold standard, it is important that management strategies for GERD be tailored to the individual patient."
AHRQ also has consumer pamphlets on treatments for GERD.
Posted: September 2011
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