Medical treatments in the short term management of reflux oesophagitis

Efficacy of mosapride plus proton pump inhibitors for treatment of gastroesophageal reflux disease: A systematic review

AIM: To assess the potential benefits of mosapride plus proton pump inhibitors (PPIs) in the treatment of gastroesophageal reflux disease.

METHODS: A literature search was performed through MEDLINE, EMBASE, and the ISI Web of Knowledge. The clinical trials that compared the benefit of mosapride plus PPI treatment with that of PPI monotherapy were analyzed. The rate of responders was evaluated by the pooled relative risk (PRR) and improvement in symptom scores was assessed by single effect size of a standardized mean, while Hedges’g was used as the effect size. Pooled effect sizes with 95%CIs were calculated using a fixed-effects model. Between-study heterogeneity was assessed using Q test and I² analyses. In addition, studies that assessed the additional efficacy of mosapride in PPI-resistant patients were also reviewed.

RESULTS: This systematic review included information on a total of 587 patients based on 7 trials. Four trials compared the efficacy of combination therapy of mosapride plus a PPI with that of PPI monotherapy. The statistical analysis for the effect of additional mosapride showed equivocal results (PRR = 1.132; 95%CI: 0.934-1.372; P = 0.205; Hedges’g = 0.24; 95%CI: 0.03-0.46; P = 0.023). No heterogeneity and publication bias were found among the studies. Three open-labeled trials assessed the additional efficacy of mosapride in PPI-resistant patients. However, since these trials did not set the control group, the results may be considerably biased.

CONCLUSION: Mosapride combined therapy is not more effective than PPI alone as first-line therapy. Whether it is effective in PPI-resistant patients needs to be determined.

Low-dose amitriptyline combined with proton pump inhibitor for functional chest pain

AIM: To investigate the efficacy of amitriptyline with proton pump inhibitor (PPI) for the treatment of functional chest pain (FCP).

METHODS: This was a randomized, open-label trial investigating the addition of low dose amitriptyline (10 mg at bedtime) to a conventional dose of rabeprazole (20 mg/d) (group A, n = 20) vs a double-dose of rabeprazole (20 mg twice daily) (group B, n = 20) for patients with FCP whose symptoms were refractory to PPI. The primary efficacy endpoints were assessed by global symptom score assessment and the total number of individuals with > 50% improvement in their symptom score.

RESULTS: The between-group difference in global symptom scores was statistically significant during the last week of treatment (overall mean difference; 3.75 ± 0.31 vs 4.35 ± 0.29, the between-group difference; P < 0.001). Furthermore, 70.6% of patients in group A had their symptoms improve by > 50%, whereas only 26.3% of patients in group B had a similar treatment response (70.6% vs 26.3%, P = 0.008). Specifically, patients in group A had a significantly greater improvement in the domains of body pain and general health perception than did patients in group B (52.37 ± 17.00 vs 41.32 ± 12.34, P = 0.031 and 47.95 ± 18.58 vs 31.84 ± 16.84, P = 0.01, respectively).

CONCLUSION: Adding amitriptyline to a PPI was more effective than a double-dose of PPI in patients with FCP refractory to a conventional dose of PPI.

Current pharmacological management of gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD), a common disorder with troublesome symptoms caused by reflux of gastric contents into the esophagus, has adverse impact on quality of life. A variety of medications have been used in GERD treatment, and acid suppression therapy is the mainstay of treatment for GERD. Although proton pump inhibitor is the most potent acid suppressant and provides good efficacy in esophagitis healing and symptom relief, about one-third of patients with GERD still have persistent symptoms with poor response to standard dose PPI. Antacids, alginate, histamine type-2 receptor antagonists, and prokinetic agents are usually used as add-on therapy to PPI in clinical practice. Development of novel therapeutic agents has focused on the underlying mechanisms of GERD, such as transient lower esophageal sphincter relaxation, motility disorder, mucosal protection, and esophageal hypersensitivity. Newer formulations of PPI with faster and longer duration of action and potassium-competitive acid blocker, a newer acid suppressant, have also been investigated in clinical trials. In this review, we summarize the current and developing therapeutic agents for GERD treatment.

Overlap of functional dyspepsia and GERD--diagnostic and treatment implications

GERD and functional dyspepsia are the two most prevalent upper gastrointestinal disorders. Gastro-oesophageal reflux is most commonly diagnosed using the cardinal symptoms of heartburn and regurgitation. Patients might also be diagnosed using a questionnaire, after empiric treatment with an acid suppressant, after upper endoscopy or by pH testing. Functional dyspepsia is best diagnosed using symptoms outlined by the Rome committee in conjunction with a normal upper endoscopy. Theoretically, distinguishing these two populations should be easy for all health-care providers. In reality, however, carefully separating out these two populations can be quite difficult, as substantial overlap exists epidemiologically, symptomatically and even diagnostically. This overlap renders precise diagnosis a challenge; given the limited treatment options, the primary goal is to identify those patients who will respond to acid suppressive therapy. Despite the frequency with which functional dyspepsia and GERD overlap, remarkably few studies have investigated this overlap. Most recommendations are based on data derived from separate studies of functional dyspepsia and GERD. A further limitation of existing studies is their failure to differentiate between the various diagnostic categories into which the individual presenting with heartburn might belong.

GERD assessment including pH metry predicts a high response rate to PPI standard therapy

Background

Inadequate response to proton pump inhibitor (PPI) therapy in patients with gastroesophageal reflux disease (GERD) is reported in up to 40%. Patients with non erosive reflux disease (NERD) have lower response rates compared to patients with erosive reflux disease (ERD); pH metry contributes to GERD diagnosis and is critical for proper diagnosis of NERD.

Aim of the study was to assess the need for doubling esomeprazole standard dose (40 mg) for 4 weeks in PPI naive patients with typical reflux symptoms and diagnosis of GERD based on endoscopy and 48 hours, wireless pH metry.

Methods

All patients underwent upper GI endoscopy. Symptoms were recorded with a structured questionnaire (RDQ) and acid exposure was determined by 48 hours, wireless pH monitoring (BRAVO). In case of abnormal acid exposure, patients received a short term treatment with esomeprazole 40 mg q.d. for 4 weeks. If symptoms persisted, patients underwent a second pH metry on PPI and the dose was increased to 40 mg b.i.d.

Results

31 consecutive patients with typical reflux symptoms underwent 48 hours pH monitoring. 22 patients (71%) had abnormal acid exposure, 9 patients had normal pH metry (29%). Of the 9 patients with normal pH metry, 2 were found with erosive esophagitis and 7 without endoscopic abnormalities.

24 patients with documented GERD received esomeprazole treatment. 21 patients achieved complete symptom resolution with 40 mg q.d. after 4 weeks (88%). Only 2 patients required doubling the dose of esomeprazole for complete symptom resolution, 1 patient remained with symptoms.

Conclusions

Patients with typical reflux symptoms and abnormal acid exposure have a high response rate to standard dose esomeprazole regardless of whether they have ERD or NERD.

Current trends in the management of gastroesophageal reflux disease: a review

Gastroesophageal reflux disease (GERD) is a chronic disorder of the upper gastrointestinal tract with global distribution. The incidence is on the increase in different parts of the world. In the last 30 to 40 years, research findings have given rise to a more robust understanding of its pathophysiology, clinical presentation, and management. The current definition of GERD (The Montreal definition, 2006) is not only symptom-based and patient-driven, but also encompasses esophageal and extraesophageal manifestations of the disease. The implication is that the disease can be confidently diagnosed based on symptoms alone. Nonerosive reflux disease (NERD) remains the predominant form of GERD. Current thinking is that NERD and erosive reflux disease (ERD) are distinct phenotypes of GERD rather than the old concept which regarded them as components of a disease spectrum. Non erosive reflux disease is a very heterogeneous group with significant overlap with other functional gastrointestinal disorders. There is no gold standard for the diagnosis of GERD. Esophageal pH monitoring and intraluminal impedance monitoring have thrown some light on the heterogeneity of NERD. A substantial proportion of GERD patients continue to have symptoms despite optimal PPI therapy, and this has necessitated research into the development of new drugs. Several safety concerns have been raised about chronic use of proton pump inhibitors but these are yet to be substantiated in controlled studies. The debate about efficacy of long-term medical treatment compared to surgery continues, however, recent data indicate that modern surgical techniques and long-term PPI therapy have comparable efficacy. These and other issues are subjects of further research.

Putting the efficacy of psychiatric and general medicine medication into perspective: review of meta-analyses

BACKGROUND

The efficacy of psychopharmacological treatments has been called into question. Psychiatrists are unfamiliar with the effectiveness of common medical drugs.

AIMS

To put the efficacy of psychiatric drugs into the perspective of that of major medical drugs.

METHOD

We searched Medline and the Cochrane Library for systematic reviews on the efficacy of drugs compared with placebo for common medical and psychiatric disorders, and systematically presented the effect sizes for primary efficacy outcomes.

RESULTS

We included 94 meta-analyses (48 drugs in 20 medical diseases, 16 drugs in 8 psychiatric disorders). There were some general medical drugs with clearly higher effect sizes than the psychotropic agents, but the psychiatric drugs were not generally less efficacious than other drugs.

CONCLUSIONS

Any comparison of different outcomes in different diseases can only serve the purpose of a qualitative perspective. The increment of improvement by drug over placebo must be viewed in the context of the disease's seriousness, suffering induced, natural course, duration, outcomes, adverse events and societal values.

The pain system in oesophageal disorders: mechanisms, clinical characteristics, and treatment

Pain is common in gastroenterology. This review aims at giving an overview of pain mechanisms, clinical features, and treatment options in oesophageal disorders. The oesophagus has sensory receptors specific for different stimuli. Painful stimuli are encoded by nociceptors and communicated via afferent nerves to the central nervous system. The pain stimulus is further processed and modulated in specific pain centres in the brain, which may undergo plastic alterations. Hence, tissue inflammation and long-term exposure to pain can cause sensitisation and hypersensitivity. Oesophageal sensitivity can be evaluated ,for example, with the oesophageal multimodal probe. Treatment should target the cause of the patient's symptoms. In gastro-oesophageal reflux diseases, proton pump inhibitors are the primary treatment option, surgery being reserved for patients with severe disease resistant to drug therapy. Functional oesophageal disorders are treated with analgesics, antidepressants, and psychological therapy. Lifestyle changes are another option with less documentation.

Cost-effectiveness of proton pump inhibitors versus laparoscopic Nissen fundoplication for patients with gastroesophageal reflux disease: a systematic review of the literature

BACKGROUND

Gastroesophageal reflux disease is a common condition in Western countries. It is unknown whether medical or surgical treatment is more cost-effective. This study was conducted to determine whether laparoscopic Nissen fundoplication or treatment by proton pump inhibitors is the most cost-effective for gastroesophageal reflux disease in the long term.

METHODS

Medline, EMBASE, and Cochrane databases were searched for articles published between January 1990 and 2010. The search results were screened by two independent reviewers for economic evaluations comparing costs and effects of laparoscopic Nissen fundoplication and proton pump inhibitors in adults eligible for both treatments. Cost and effectiveness or utility data were extracted for both treatment modalities. The quality of the economic evaluations was scored using a dedicated checklist, as were the levels of evidence.

RESULTS

Four publications were included; all were based on decision analytic models. The economic evaluations were all of similar quality and all based on data with a variety of evidence levels. Surgery was more expensive than medical treatment in three publications. Two papers reported more quality-adjusted life-years for surgery. However, one of these reported more symptom-free months for medical treatment. In two publications surgery was considered to be the most cost-effective treatment, whereas the other two favored medical treatment.

CONCLUSIONS

The results with regard to cost-effectiveness are inconclusive. All four economic models are based on high- and low-quality data. More reliable estimates of cost-effectiveness based on long-term trial data are needed.

Guidance on the use of over-the-counter proton pump inhibitors for the treatment of GERD

OBJECTIVE

The aim of this paper was to develop a guideline on the over-the-counter management of gastroesophageal reflux disease with proton pump inhibitors (i.e. omeprazole).

SETTING

A meeting of internationally renowned gastroenterologists in January 2009, in Berlin, Germany.

METHODS

An expert panel group of gastroenterologists convened to develop a consensus-based algorithm for pharmacists for over-the-counter (OTC) treatment with proton pump inhibitors (PPIs). Key considerations were the short-term safety and efficacy of PPIs, and the extent of the risk to the sufferer, owing to the treatment not being controlled by a physician. Main outcome measures A consensus-based treatment algorithm for the OTC management of gastroesophageal reflux disease and evidence-based guidance on the use of OTC PPIs.

RESULTS

As defined by the treatment algorithm, the pharmacist should first confirm the diagnosis based on the presence of typical symptoms and secondly, as a result, rule out general practitioner referral. The third step focuses on the nature, severity and frequency of the symptoms--the patients who might have the highest benefit from a short course (14 days) of OTC PPIs are those with less than three episodes of heartburn and/or acid regurgitation per week. Patients who have three or more episodes per week can use the OTC PPIs but should also be encouraged to visit a physician, and those who already have a diagnostic work-up can use proton pump inhibitors as rescue treatment if they are known responders. Guidance for pharmacists, in the form of questions and answers, summarises the current published clinical experience with PPIs in terms of their efficacy and safety, and optimal treatment schedule. Conclusions Gastroesophageal reflux disease imposes a considerable burden on sufferers. Owing to their accepted efficacy and safety, PPIs are becoming popular as OTC options for the treatment of gastroesophageal reflux disease symptoms such as heartburn and acid regurgitation. Effective self-management of gastroesophageal reflux disease with OTC PPIs, e.g. omeprazole, could lead to lasting freedom from symptoms and improved quality of life for sufferers.

Pharmacological management of GERD: where does it stand now?

Gastroesophageal reflux disease (GERD) is very common and advances in drug development over recent years have markedly improved GERD management. A wide range of medications are currently used in GERD treatment, including antacids, Gaviscon, sucralfate, histamine-2 receptor antagonists and prokinetics. However, proton pump inhibitors (PPIs) remain the mainstay of treatment for GERD owing to their profound and consistent inhibitory effect on acid secretion. Despite the presence of a wide armamentarium of therapeutic modalities for GERD, many areas of unmet needs remain. Drug development has focused primarily on improving PPI efficacy, reducing the transient lower esophageal sphincter relaxation rate, attenuating esophageal sensitivity and developing esophageal mucosal protectants.

Mosapride as an adjunct to lansoprazole for symptom relief of reflux oesophagitis

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT Reflux oesophagitis is a common clinical disorder associated with significant morbidity. Proton pump inhibitors are the current pharmacotherapy of choice, but not all treated patients achieve symptom relief. Little is known about the efficacy of mosapride, a prokinetic agent which decreases episodes of gastro-oesophageal reflux, as an adjunct to proton pump inhibitors in improving the symptoms of reflux oesophagitis. WHAT THIS STUDY ADDS Mosapride was generally not more effective than placebo as an adjunct therapy to a standard dose of lansoprazole in decreasing the symptom burden of patients with reflux oesophagitis. However, in a subgroup with more severe symptoms, combination therapy with lansoprazole and mosapride was possibly superior to monotherapy with lansoprazole. AIMS To investigate if mosapride, a prokinetic agent, was an effective adjunct to acid suppression in improving the symptoms of reflux oesophagitis. METHODS Patients (n= 96) with reflux oesophagitis were randomly assigned to either mosapride (5 mg three times daily) or placebo for 4 weeks. Symptom severity was assessed by a validated questionnaire at enrolment, 4 and 8 weeks after medication. The primary outcome for the first 4 weeks was decrease in symptom scores. After a 3 day washout period, patients initially allocated to mosapride crossed over to placebo and vice versa for the next 4 weeks. The outcome of the second phase was maintenance of symptom control. All patients received lansoprazole (30 mg once daily) throughout study. RESULTS The decreased symptom score after 4 weeks of treatment with lansoprazole and mosapride (n= 50) was 13.42 +/- 1.16 (mean +/- SEM), similar to that of lansoprazole plus placebo (10.85 +/- 1.03, n= 46), with an insignificant difference of 2.57 (95% CI -0.53, 5.67, P= 0.103). However, a sub-group analysis for patients with pre-treatment scores of >18 points (n= 48) revealed that lansoprazole plus mosapride achieved a greater reduction of symptom score than lansoprazole plus placebo (18.22 +/- 1.91 vs. 12.88 +/- 1.65; mean difference of 5.34, 95% CI 0.28, 10.40, P= 0.039). In the second phase, there was no difference between lansoprazole with mosapride or placebo in maintaining symptom control (39/44 or 86.64% vs. 41/50 or 82%, P= 0.401). Subgroup analysis for those with substantial residual symptoms revealed similar results. CONCLUSION Compared with placebo, mosapride generally does not provide additional benefit to a standard dose of lansoprazole in patients with reflux oesophagitis, except possibly in the subgroup of severely symptomatic patients.

A double-blind, controlled study comparing lafutidine with placebo and famotidine in Japanese patients with mild reflux esophagitis

PURPOSE

This randomized, double-blind, controlled study examined whether lafutidine is superior to placebo and non-inferior to famotidine in terms of healing rates as assessed by endoscopy in Japanese patients with mild reflux esophagitis. Safety and improvement in symptoms of heartburn were also assessed.

METHODS

Patients with an endoscopic diagnosis of grade A or B reflux esophagitis according to the Los Angeles classification were randomly assigned to receive lafutidine (20 mg/day), famotidine (40 mg/day), or placebo for 8 weeks.

RESULTS

Of the 584 patients enrolled in the study, 447 were diagnosed to have grade A or B reflux esophagitis by the Endoscopic Assessment Committee. Healing rates at 8 weeks were 71.0% (115/162) in the lafutidine group, 61.4% (86/140) in the famotidine group, and 9.7% (14/145) in the placebo group. Lafutidine was thus demonstrated to be superior to placebo and non-inferior to famotidine. As compared with placebo, lafutidine significantly improved symptoms of heartburn.

CONCLUSIONS

Lafutidine has a high endoscopic healing rate and improves symptoms of heartburn in patients with mild reflux esophagitis. Lafutidine is considered a promising treatment option for mild reflux esophagitis.

Diagnosis and management of Barrett's esophagus for the endoscopist

In Barrett's esophagus, the stratified squamous epithelium lining the esophagus is replaced by specialized intestinal-type columnar epithelium. The prevalence of Barrett's esophagus has ranged from 0.9% to 4.5%. The rate of progression from Barrett's esophagus to esophageal adenocarcinoma is 0.5% per patient-year. Proton-pump inhibitors are the mainstay of symptom control in Barrett's patients. Nondysplastic Barrett's and Barrett's with low-grade dysplasia (LGD) are typically managed by periodic surveillance. Radiofrequency ablation is being evaluated as a modality for managing nondysplastic Barrett's and Barrett's with LGD. The options for the management of Barrett's patients with high-grade dysplasia (HGD) include endoscopic therapy, surgery, and intensive surveillance until biopsy reveals adenocarcinoma. Endoscopic therapy involves endoscopic mucosal resection (EMR) and ablation. More aggressive techniques such as endoscopic submucosal dissection and larger segment endoscopic mucosal resection are under study. In this review, we discuss the diagnosis and management of Barrett's esophagus. The recommendations from the major gastroenterologic societies and the current and investigational endoscopic modalities for the management of Barrett's esophagus with and without dysplasia are reviewed.

Transoral incision free fundoplication (TIF) - A new paradigm in the surgical treatment of GERD

An estimated 10 billion dollars is spent treating gastro-oesophageal reflux disease (GERD) in the USA every year. The present article reports a case of the safe and successful use of transoral incisionless fundoplication (TIF) using the EsophyX90™ device in the surgical treatment of GERD.

Delayed-release oral suspension of omeprazole for the treatment of erosive esophagitis and gastroesophageal reflux disease in pediatric patients: a review

Omeprazole is a proton-pump inhibitor indicated for gastroesophageal reflux disease and erosive esophagitis treatment in children. The aim of this review was to evaluate the efficacy of delayed-release oral suspension of omeprazole in childhood esophagitis, in terms of symptom relief, reduction in reflux index and/or intragastric acidity, and endoscopic and/or histological healing. We systematically searched PubMed, Cochrane and EMBASE (1990 to 2009) and identified 59 potentially relevant articles, but only 12 articles were suitable to be included in our analysis. All the studies evaluated symptom relief and reported a median relief rate of 80.4% (range 35%–100%). Five studies reported a significant reduction of the esophageal reflux index within normal limits (<7%) in all children, and 4 studies a significant reduction of intra-gastric acidity. The endoscopic healing rate, reported by 9 studies, was 84% after 8-week treatment and 95% after 12-week treatment, the latter being significantly higher than the histological healing rate (49%). In conclusion, omeprazole given at a dose ranging from 0.3 to 3.5 mg/kg once daily (median 1 mg/kg once daily) for at least 12 weeks is highly effective in childhood esophagitis.

Pantoprazole: a proton pump inhibitor

Pantoprazole is a proton pump inhibitor (PPI) that binds irreversibly and specifically to the proton pump, thereby reducing gastric acid secretion. Pantoprazole has a relatively long duration of action compared with other PPIs, and a lower propensity to become activated in slightly acidic body compartments. To date, no drug-drug interactions have been identified with pantoprazole in numerous interaction studies. Overall, in the short-term (8-10 weeks) initial treatment of gastro-oesophageal reflux disease (a condition that occurs when the reflux of gastric contents causes troublesome symptoms and/or complications) and long-term (6-24 months) maintenance therapy, oral pantoprazole 20 or 40 mg/day demonstrated similar efficacy to omeprazole, lansoprazole and esomeprazole and greater efficacy than histamine type 2 receptor antagonists. Pantoprazole is also effective in treating and preventing NSAID-related gastric and gastroduodenal injury. The optimal adult oral dose for gastric acid-related disorders is pantoprazole 40 mg once daily. Although data are limited, pantoprazole 20 or 40 mg/day was effective and well tolerated in the treatment of acid-related disorders in children and adolescents. Pantoprazole was also well tolerated in adults with acid-related disorders in short- and long-term studies. Thus, pantoprazole is a valuable agent for the management of acid-related disorders.

Gastroesophageal reflux disease: medical or surgical treatment?

BACKGROUND

Gastroesophageal reflux disease is a common condition with increasing prevalence worldwide. The disease encompasses a broad spectrum of clinical symptoms and disorders from simple heartburn without esophagitis to erosive esophagitis with severe complications, such as esophageal strictures and intestinal metaplasia. Diagnosis is based mainly on ambulatory esophageal pH testing and endoscopy. There has been a long-standing debate about the best treatment approach for this troublesome disease.

METHODS AND RESULTS

Medical treatment with PPIs has an excellent efficacy in reversing the symptoms of GERD, but they should be taken for life, and long-term side effects do exist. However, patients who desire a permanent cure and have severe complications or cannot tolerate long-term treatment with PPIs are candidates for surgical treatment. Laparoscopic antireflux surgery achieves a significant symptom control, increased patient satisfaction, and complete withdrawal of antireflux medications, in the majority of patients.

CONCLUSION

Surgical treatment should be reserved mainly for young patients seeking permanent results. However, the choice of the treatment schedule should be individualized for every patient. It is up to the patient, the physician and the surgeon to decide the best treatment option for individual cases.

Intravenous proton pump inhibitors: an evidence-based review of their use in gastrointestinal disorders

Conditions requiring inhibition of acid secretion, such as gastro-oesophageal reflux disease or peptic ulcers, are very common and their prevalence is expected to rise as they are seen predominantly in the elderly. The general basis of treatment with antisecretory agents is to maintain gastric pH >4 for a substantial proportion of the 24-hour cycle. Among the drugs available to inhibit acid secretion, proton pump inhibitors (PPIs) have been shown to have the best benefit-risk ratio and have been used widely. Intravenous administration of a PPI provides gastric acid suppression faster than oral administration does. Whereas some indications for the use of intravenous PPIs are widely known, mostly for acute management of peptic ulcer bleeding, there are some controversies surrounding their use in other conditions such as stress-induced mucosal damage. There is still a need to define the best schedule for intravenous PPI administration (i.e. bolus infusion or constant infusion), the optimal time to switch from intravenous to oral administration and the choice of which agent is best. In most of the clinical scenarios where PPIs are recommended, they can be administered via either oral or enteral routes, unless the patient is nil by mouth. Since there are no head-to-head comparisons of the different intravenous PPIs available worldwide (omeprazole, lansoprazole, pantoprazole and esomeprazole), the rule might be to choose the drug with the best proven efficacy in each specific condition. Indeed, the key difference between them, the ability to reach and to maintain a threshold gastric pH, might not necessarily translate into clinically significant differences.

Clinical practice. Gastroesophageal reflux disease

A 53-year-old man, who is otherwise healthy and has a 20-year history of occasional heartburn, reports having had worsening heartburn for the past 12 months, with daily symptoms that disturb his sleep. He reports having had no dysphagia, gastrointestinal bleeding, or weight loss and in fact has recently gained 20 lb (9 kg). What would you advise regarding his evaluation and treatment?

Does the evidence show that prokinetic agents are effective in healing esophagitis and improving symptoms of GERD?

Gastroesophageal reflux disease (GERD) is common in affluent societies, and its prevalence is also on the rise in developing regions such as Southeast Asia.1 When heartburn and regurgitation are the dominant symptoms, a diagnosis of GERD can be made. Manzotti and colleagues report in Open Medicine the findings of a systematic review in which they evaluate the use of prokinetic agents in the treatment of reflux esophagitis.

The lessons learned from randomized clinical trials of GERD

Despite the huge number of randomized controlled clinical trials published on gastro-oesophageal reflux disease, the translation of the information gathered into clinical practice is rather limited. The aim of this article is to summarize the results of pivotal randomized controlled clinical trials and review articles on reflux disease and evaluate to what extent their results can be applied to current clinical practice. We reviewed the most relevant randomized controlled clinical trials and reviews since the publication of the first randomized controlled clinical trial on reflux oesophagitis (1978) to date. Six areas were explored, namely: (1) diagnostic "entry" criteria, (2) efficacy parameters, (3) duration of therapy, (4) degree of antisecretory effect, (5) placebo effect, (6) follow-up data. Gastro-oesophageal reflux disease is now the most frequent upper GI disorder treated by gastroenterologists in Europe and North America. There is still a dearth of information regarding the natural history of the disease. The types of information generated through randomized controlled clinical trials have had only limited applicability to routine clinical practice. In the future, large cooperative databases accumulating the clinical histories of a great variety of gastro-oesophageal reflux disease patients may help to provide us with the much needed insights into the natural history of this common disorder.