Treatment of Acid Reflux Disease is primarily medical, the mainstays being lifestyle modifications and drug therapy. The goals of treatment are to relieve symptoms and prevent relapse and complications. All patients should be advised about lifestyle modifications that help reduce symptoms and prevent relapse. Antacids or antacid-alginate combinations are recommended for safe, prompt, inexpensive relief of heartburn. The same agents, however, are poorly suited for regular use because of poor palatability and durability and side effects such as diarrhea, constipation, and possible magnesium or aluminum toxicity in renal patients. Protection against recurrence of heartburn is provided by acid-suppressing medications such as H2-receptor antagonists and PPIs. H2-receptor antagonists reduce gastric acid secretion moderately by inhibiting one of three acid-stimulating receptors on the basolateral membrane of the parietal cell. When prescribed twice a day, they can control symptoms in about 50% of Acid Reflux Disease patients and heal erosions in about 30%. PPIs irreversibly inhibit the H+, K+-ATPase or proton pump, the final common pathway for acid secretion on the apical membrane of the parietal cell. Consequently, PPIs markedly reduce gastric acidity with once-a-day dosing and provide relief of symptoms and healing of lesions in about 80 to 90% of Acid Reflux Disease patients. H2-receptor antagonists (+30 years) and PPIs (≈15 years) have excellent safety profiles. PPI safety beyond 15 years remains unclear because of uncertainty about the long-term risk for chronic gastric hypoacidity and hypergastrinemia. Although vitamin B12 levels can be reduced with chronic PPI use, clinically significant vitamin B12 deficiency has not been reported, so an increase in vitamin B12 intake is not currently recommended.
Early endoscopy is indicated for those with alarm symptoms. Endoscopy is also indicated for patients who fail once-a-day PPI therapy to confirm the diagnosis and assess severity, including the presence of Barrett's esophagus (see later). Testing for H. pylori is not recommended because the organism is not etiologic in Acid Reflux Disease and, when eradicated, may make treatment more difficult.
Failures with once-a-day PPI therapy are treated with twice-daily PPI therapy with or without H2-receptor antagonists at bedtime for 6 to 8 weeks, and patients who fail this regimen undergo esophageal pH monitoring during therapy to assess for control of esophageal acidity. If the acidity is controlled, the symptoms are not mediated by acid.
Effective therapy is often accompanied by relapse when medication ceases, especially in patients with erosive esophagitis, in whom maintenance therapy is indicated. Patients requiring maintenance therapy should undergo at least one endoscopy procedure to determine whether Barrett's esophagus is present. If endoscopy reveals NERD, no further endoscopy is necessary and treatment is guided by symptoms. If endoscopy reveals erosive esophagitis, treatment to healing should be documented by endoscopy so that Barrett's esophagus can be effectively established or excluded. Once Barrett's esophagus is excluded, endoscopy is unnecessary and treatment is guided by symptoms because subsequent relapse and treatment will rarely result in Barrett's esophagus.
