American College of Gastroenterology guideline for diagnosing and managing GERD

Reference

Katz PO, Dunbar KB, Schnoll-Sussman FH, Greer KB, Yadlapati R, Spechler SJ. ACG clinical guideline for the diagnosis and management of gastroesophageal reflux disease.. Am J Gastroenterol 2022;117(1):27-56.

Synopsis

The American College of Gastroenterology convened a panel to update its 2013 guideline on managing persons with gastroesophageal reflux disease (GERD). Although the paper doesn’t describe how the panel was selected, the panel members all appear to be gastroenterologists. The panel members identified specific questions and a research librarian performed a literature search on each question. The panel members assessed the quality of the underlying research to guide their recommendations. The panel made many specific recommendations and identified key concepts, some of which are relevant to primary care clinicians. A few of these are summarized below. Additionally, the panel recommends searching for non-GERD causes of extraesophageal symptoms (cough, asthma, etc.) before ascribing them to GERD and, after that, in the absence of GERD symptoms, patients should undergo reflux testing before taking a proton pump inhibitor (PPI). Finally, the panel recognizes that some patients require long-term PPI therapy and some harms have been associated with this treatment. The panel suggests advising patients that PPIs are the most effective medical treatment for GERD and that the studies reporting an association between the long-term use of PPIs and harms such as pneumonia, gastric cancer, and so forth are flawed; they do not establish a cause-and-effect relationship between PPIs and the adverse conditions. The panel states that the benefits of PPIs outweigh their theoretical risks. Recommendation Quality of Evidence Strength of Recommendation An 8-week trial of empiric PPIs in persons with classic symptoms and no alarm symptoms Moderate Strong Attempt to discontinue PPIs after a successful 8-week trial Low Conditional Endoscopy is the preferred initial test in persons with dysphagia, alarm symptoms, and with multiple risk factors for Barrett's esophagus Low Conditional Persons with suspected GERD but unremarkable endoscopy should have reflux monitoring off therapy Low Strong Overweight or obese persons with GERD should attempt weight loss Moderate Strong Avoid meals within 2 to 3 hours before bedtime Low Conditional Avoid tobacco and trigger foods Low Conditional Elevate the head of the bed Low Conditional Use PPIs over histamine receptor antagonists in persons with erosive esophagitis High Strong Administer PPIs 30 minutes to 60 minutes before a meal rather than at bedtime Moderate Strong In the absence of Barrett's or erosive esophagitis, attempt to discontinue PPIs in persons whose symptoms have resolved Low Conditional Don't use prokinetic agents in the absence of objective evidence for gastroparesis Low Strong Only administer sucralfate to pregnant women Low Strong Table. Select summary of recommendations relevant to primary care