Longterm strategy

Once a patient has been shown to improve with acid suppression therapy, the question of long-term management becomes evident. Since GERD is in most instances a chronic (relapsing) disease, a concept for the further treatment is needed in the vast majority. The speed of recurrence of symptoms after cessation of treatment represents a reliable predictor for the necessity of ongoing therapy: those who will become symptomatic within a few days after stopping treatment will probably require (almost) daily doses to achieve prolonged remission whereas those remaining asymptomatic for a considerable period can most likely treated by on demand therapy. Particularly in NERD, cessation of therapy after treatment of an acute episode of reflux symptoms is advisable since about half of the patients will remain in symptomatic remission within a 6-month interval. In symptomatic patients, tailoring of long-term treatment can be well orientated at the presence of symptoms whereas endoscopic guidance is predominantly required only in patients without or with minor reflux symptoms. Reflux oesophagitis initially with high degree of severity as well as complicated reflux disease will most probably require daily administration of PPI.

The strategy with on demand therapy has been developed primarily for patients with NERD since freedom of heartburn and other reflux symptoms is the only therapeutic goal in this group of patients. However, many patients overwhelmingly with mild reflux oesophagitis will also switch voluntarily to an on demand concept as long as they remain symptom free. Since there is no evidence that such a strategy will bear the risk for the development of Barrett's oesophagus or other complications of reflux disease, symptom-orientated drug administration can be well accepted also in patients with low-grade oesophagitis since absence of heartburn is associated with healing of lesions in the vast majority [8] despite the fact that endoscopic investigations may reveal some minor peptic lesions during follow-up.

Whereas PPI are the acute treatment of choice for all forms of reflux disease, the question remains whether other compounds, in particular H2-blockers which are attractive due to low costs, can be regarded as an alternative in long-term management in accordance with the step-down concept. So far, there are very little reliable data which demonstrate unequivocally the benefits from such an H2-receptor antagonist treatment e.g. compared to PPI. It seems, however, justified to try such an approach in patients with mild symptoms requiring only minute doses of PPI to remain free of heartburn. Patients should be advised to return to the office if symptom control is unsatisfactory after switching to H2-blockers.

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