On demand therapy of reflux oesophagitis--a prospective study of symptoms, patient satisfaction and quality of life

Cost minimization of on-demand maintenance therapy with proton pump inhibitors in nonerosive gastroesophageal reflux disease

On-demand proton pump inhibitor maintenance therapy is one of the suggested strategies for patients with nonerosive gastroesophageal reflux disease who achieve symptom remission after 4 weeks of continuous treatment. This review evaluates the difference in cost and quality of life of six on-demand proton pump inhibitor maintenance strategies in patients with nonerosive gastroesophageal reflux disease. This was performed by decision analysis and Markov modeling of costs (from the perspective of the healthcare service and society) and utility up to 12 months. Median utility scores associated with each proton pump inhibitor ranged from 0.731 to 0.745 quality-adjusted life years and were not statistically different. Annual expected cost, however, was statistically different among the different drugs and the following cost-minimization ranking was obtained for median costs to the healthcare service and society, respectively: rabeprazole (euro 181, euro 295), pantoprazole (euro 223, euro 341), lansoprazole (euro 249, euro 370), omeprazole 10 mg (euro 297, euro 412), esomeprazole (euro 295, euro 419) and omeprazole 20 mg (euro 405, euro 528). Unit cost of proton pump inhibitors was the major determinant of cost to the healthcare service, while the number of productivity days lost due to symptoms was the major determinant of cost to society. In Italy, on-demand use of rabeprazole for maintenance therapy of nonerosive gastroesophageal reflux disease incurs the least cost in comparison with the other proton pump inhibitors evaluated.

H. pylori eradication prevents the progression of gastric intestinal metaplasia in reflux esophagitis patients using long-term esomeprazole

OBJECTIVES

This study aimed to determine whether Helicobacter pylori eradication limits the progression of precancerous changes, manifested as intestinal metaplasia (IM), in patients with reflux esophagitis using long-term esomeprazole.

METHODS

Three hundred twenty-five reflux esophagitis patients were enrolled and randomly assigned to (i) the H. pylori-positive eradication group receiving 1-week triple therapy (n=105); (ii) H. pylori-positive non-eradication controls (n=105); and (iii) H. pylori-negative controls (n=115). All the patients received continuous esomeprazole until sustained symptomatic response, and when possible, shifted to on-demand therapy (ODT) thereafter. Serial gastroscopy was scheduled on enrollment and at the end of the first and second years to assess the prevalence and progression or regression of gastric atrophy (AT) and IM.

RESULTS

There were 93 patients in the H. pylori-eradication group, 83 in the non-eradication controls, and 100 in the negative controls to complete the study. The negative controls had no progression of AT and IM during follow-up. For the H. pylori-positive eradication group, there was significant regression of AT and IM during follow-up (P<0.05). In the H. pylori-positive non-treated controls, the prevalence rates of AT and IM were significantly greater on the second year than on enrollment (P<0.05). During the second-year follow-up, the patients in the eradication group achieved more regression and less development of AT and IM than did the non-eradication controls (P<0.001).

CONCLUSIONS

In patients using long-term esomeprazole for reflux esophagitis, screening for and eradicating H. pylori infection are necessary in order to limit the progression or cause the regression of gastric precancerous changes.

Effect of esomeprazole on symptom relief and improvement of quality of life in gastroesophageal reflux disease patients

AIM: To compare the efficacy and safety of esomeprazole with omeprazole on symptom relief and improvement of quality of life in gastroesophageal reflux disease (GERD) patients.

METHODS: A prospective, randomized controlled study was designed. A total of 78 GERD patients diagnosed with endoscope and/or their 24 h esophageal pH monitored were randomized into esomeprazole treatment group and omeprazole treatment group (39 patients each group). Patients in the two groups received standard doses of esomeprazole (20 mg, twice a day, po) or double doses of omeprazole (20 mg, twice a day, po) for 8 wk. Symptom relief, efficiency, cure rate and quality of life were compared between the two groups.

RESULTS: Seven-six patients completed the 8-week therapy. One patient in each group was dropped out because of running counter to the RE testing procedure. Symptoms of the two groups at weeks 4 and 8 were significantly improved. Symptoms of patients in the esomeprazole group were much better improved than those in the omeprazole group (P < 0.01). There was a significant difference in remission of heartburn and chest pain between the two groups (78.3% vs 45.5%, 64.3% vs 37.5%, P < 0.05). However, there was no significant difference in remission of acid regurgitation and dysphagia between the two groups. There was a significant difference in the efficiency and cure rate at weeks 4 and 8 between the two groups (4 wk: 88.8% vs 59.3%, 80.0% vs 51.9%, P < 0.05; 8 wk: 96.0% vs 70.4%, 88.0% vs 63.1%, P < 0.05). The quality of life, cure rate, vitality (VT) and social function (SF) were much better improved in the esomeprazole group than in the omeprazole group (92.5 ± 5.7 vs 85.3 ± 7.1, 85.2 ± 4.6 vs 76.8 ± 6.5, P < 0.05).

CONCLUSION: Standard doses of esomeprazole have better effects on improving heartburn and chest pain, cure rate, VT and SF in GERD patients than double doses of omeprazole.

Medical management of gastroesophageal reflux disease

Gastroesophageal reflux disease is a common worldwide disorder. Most patients have typical symptoms of heartburn, regurgitation and exacerbation of symptoms with large meal volumes, fatty meals, recumbency or bending forward. Patients who show typical symptoms for under 10 years may be treated empirically with lifestyle and dietary modifications plus acid-suppressing medications. The recent decrease in cost, established safety and wide availability of proton pump inhibitors make them the best choice for monotherapy. Other medical therapies include antacids, H(2) receptor antagonists and prokinetic agents. Patients who have alarm symptoms or long-standing symptoms should have an esophagoscopy to evaluate for complications of reflux. Patients who do not respond to therapy should have a test to confirm the diagnosis of gastroesophageal reflux disease.

A 9 year prospective cohort study of endoscoped patients with upper gastrointestinal symptoms

Despite the high prevalence of upper gastrointestinal symptoms and associated costs of diagnosis and management, evidence regarding long-term outcomes is scant. We studied symptom outcomes 18 months (FU1) and 8/9 years (FU2) post-index endoscopy to identify demographic, diagnostic and treatment factors associated with outcomes. A retrospective review of medical records at two Australian teaching hospitals identified a cohort of 302 patients who had an index endoscopy (performed by 23 endoscopists) 18 months previously. Patients were interviewed at FU1 and FU2. In total 34% (95%CI: 29.0 39.8) of patients were asymptomatic at FUI and 41% (95%CI: 35.6-46.6) at FU2. For 63%, outcomes at FUI predicted long-term outcome, with 19% (95%CI: 14.6-23.4) asymptomatic and 44% (95%CI: 38.4-50.0) symptomatic at both times. Those whose symptom status changed were as likely to deteriorate as improve (p > 0.05). Number and severity of presenting symptoms (F = 3.3, df = 3,277, p < 0.05) and older age (F = 2.8, df = 2,301, p < 0.05) were associated with poorer outcomes. Long-term outcome was unrelated to endoscopic diagnosis. Those symptomatic were significantly more likely to be on proton pump inhibitors (PPIs) or Histamine2 Receptor Antagonists (H2RAs) than those who were asymptomatic. Use of PPIs at FU2 was associated with a significantly better outcome than use of H2RAs. However this impact was relatively small, with 69% of patients on PPIs and 84% on H2RAs symptomatic at FU2. Upper gastrointestinal symptoms prompting endoscopy are chronic for the majority of patients regardless of diagnosis. Endoscopic diagnosis is of limited value in predicting long-term outcomes. The association between poor outcome and use of H2RAs and PPIs challenges views about their long-term effectiveness in symptom control.

Review article: the long-term use of proton-pump inhibitors

More than 15 years after the launch of omeprazole in 1988, proton-pump inhibitors remain central to the management of acid-suppression disorders and are unchallenged with regard to their efficacy and popularity among doctors and patients. They are considered safe despite early concerns about the possibility of an association with cancer and gastric atrophy; current concerns about long-term proton-pump inhibitor therapy are centred mainly on a possible association with fundic gland polyps and between Helicobacter pylori and gastric atrophic changes. Long-term proton-pump inhibitor usage accounts for the majority of the total proton-pump inhibitor usage. Long-term usage is difficult to define and most patients take proton-pump inhibitors non-continuously. Data indicate that a substantial proportion of long-term users do not have a clear indication for their therapy and there is thus room for reduction or rationalization of treatment. Overall, on-demand therapy is more cost-effective than continuous therapy and should be considered wherever possible.

Effects of pantoprazole 20 mg in mildgastroesophageal reflux disease: Once-daily treatment in the acute phase, and comparison of on-demand versus continuous treatment in the long term

BACKGROUND

Gastroesophageal reflux disease (GERD) is a chronic disorder,and although effective short-term treatment strategies are known, the rate of relapse within 1 year is as high as 90% despite successful acute treatment. Consequently, most patients with GERD require an effective long-term management strategy to achieve adequate symptom control and maintain mucosal healing.

OBJECTIVE

The present study was undertaken to compare the control ofGERD symptoms during long-term (24-week) treatment with pantoprazole 20 mg used on-demand or continuously in patients with mild GERD after complete relief of acute GERD symptoms.

METHODS

Patients with endoscopically confirmed Savary/Miller grade 0(normal mucosa) or I (patchy red lesions without white coating or with central white coating) GERD were enrolled in this multinational, multicenter study comprising 2 phases. In the first phase, which was open label, patients were treated with pantoprazole 20 mg QD for 4 weeks. The presence and intensity of the symptoms of heartburn, acid regurgitation, and pain on swallowing were assessed. In the second phase, which was an open-label, 24-week, randomized design, only patients completely free of GERD symptoms after acute treatment were included. During this phase, on-demand treatment with pantoprazole 20 mg was directly compared with continuous treatment. The rate of failure to control GERD symptoms after 24 weeks of treatment was estimated using the Kaplan-Meier method. Subsequently, the difference between treatments (on-demand minus continuous) and its 95% CI were calculated, and the on-demand treatment was tested for noninferiority using a predefined noninferiority margin of 20%. The mean daily symptom loads were compared between the treatment groups using the 1-sided Wilcoxon rank sum test on a 5% α level. The point estimate of the difference was determined using the Hodges-Lehman estimator and the 1-sided 95% CI according to Moses. The number of patients unwilling to continue due to insufficient control of heartburn, acid regurgitation, and pain on swallowing was analyzed using the Kaplan-Meier (time-to-event) analysis. Analysis was performed in the same manner as for the rate of failure to control GERD symptoms, but the 95% CI was interpreted for statistical superiority.

RESULTS

A total of 558 patients were enrolled in this study. At the end of theacute phase, 82.1% of patients in the per-protocol (PP) population and 79.1% in the intent-to-treat (ITT) population were relieved of all GERD symptoms, and subsequently entered the long-term phase. After 24 weeks of treatment, analysis of the failure rates revealed that on-demand treatment was noninferior to continuous treatment because the 95% CI was completely below 20% (ITT, 12.1% difference [95% CI, -∞ to 18.9%]; PP, 10.1% difference [95% CI, -∞ to 17.7%]). The higher perceived mean (SD) daily symptom load in the on-demand group (ITT, 1.26 [1.491 vs 0.82 [1.341) was balanced by the reduced tablet intake in that group (PP, 0.51 [0.31 ] vs 0.97 [0.11 ] tablets/d; P < 0.001). With respect to the rate of patients unwilling to continue treatment, no statistically significant difference was observed between the on-demand and continuous groups (ITT/PP, 0.95/1.13 vs 0.95/1.26).

CONCLUSIONS

In this study of pantoprazole 20 mg tablets in patients withmild GERD, patients receiving on-demand treatment benefited despite their higher symptom load. The similar rates of unwillingness to continue treatment in both groups might suggest that patients were satisfied with the on-demand treatment strategy. On-demand treatment with pantoprazole 20 mg was found to be noninferior compared with continuous therapy with regard to symptom control. Both on-demand and continuous treatments were well tolerated.

Long-term outcome of surgically and medically treated patients with gastroesophageal reflux disease: a matched-pair follow-up study

OBJECTIVE

A recent randomized study has shown that the long-term effects of continuous medical treatment of gastroesophageal reflux disease (GERD) with a proton-pump inhibitor are comparable to those of open fundoplication. We compared the long-term effects of anti-reflux surgery with those of medical care according to clinical practice.

MATERIAL AND METHODS

This is a questionnaire-based 3-10 years follow-up study of 373 patients with GERD operated on in two hospitals with either open or laparoscopic fundoplication, and pair-matched non-operated controls treated medically according to clinical practice. The controls were matched for hospital, age, sex, follow-up time, degree of esophagitis, presence of hiatus hernia and Barrett's esophagus. The questionnaires used for symptoms and health-related quality of life (QoL) were the Gastrointestinal Symptoms Rating Scale and the Psychological General Well-Being Index, respectively.

RESULTS

Response rates were about 80%, and 179 pairs of operated patients and controls remained for analysis (102 based on laparoscopic and 77 on open fundoplication). Independently of the surgical technique, the operated patients suffered at the follow-up from significantly (p <0.001) fewer reflux symptoms than the non-operated controls, the mean scores being 1.34 and 2.51, respectively. The operated patients suffered from slightly more symptoms of indigestion (p <0.05). No consistent significant differences between the groups were found for QoL. Significant differences in QoL in favor of the operated patients were found when dealing only with the 43 pairs with no concurrent disease.

CONCLUSION

The study shows that in our area anti-reflux surgery is more effective in relieving reflux symptoms than medical care according to clinical practice.

Effects of effervescent ranitidine on gastric pH: comparison with almagate and placebo in fasting and postprandial conditions

AIM

To compare the effect of effervescent ranitidine, almagate (magnesium carbonate-aluminium hydroxide) and placebo on gastric pH, in fasting and postprandial conditions.

METHODS

Twelve healthy volunteers underwent a gastro-oesophageal pH monitoring on three different occasions after the administration of each of the following randomly allocated treatments: almagate, effervescent ranitidine and placebo. Treatment effects were assessed in fasting and postprandial conditions. Onset and duration of alkalinization, percentage of time with pH > 4 and median gastric pH after treatments were calculated in both periods.

RESULTS

Onset of action of effervescent ranitidine was similar to almagate in fasting [median 1.2 min (IQR: 0.6-12.7) vs. 2.9 min (0.4-227.6)] and postprandial conditions [1.4 min (0.5-4.9) vs. 4.1 min (1.3-63.8)] and both were significantly faster than placebo [fasting 211.1 min (2.7-240); postprandial 240 min (175.6-240)]. The duration of action of effervescent ranitidine was statistically significant longer than almagate in fasting [235 min (105.2-239.4) vs. 19.4 min (6.7-38.8)] and postprandial conditions [171.8 min (133.2-239.5) vs. 61.3 min (44.7-91.9)]. Effervescent ranitidine was more effective than almagate in increasing the percentage of time with a pH > 4 both in fasting (73.9% vs. 7.3%) and postprandial (59.1% vs. 21.3%).

CONCLUSIONS

Effervescent ranitidine shows an effect on gastric pH as fast as almagate but provides a duration of alkalinization longer than almagate, in both fasting and postprandial conditions.

Patient assessment of treatment satisfaction: methods and practical issues

Measurement of treatment satisfaction in gastro-oesophageal reflux disease (GORD) is compromised by an insufficient conceptual foundation and poor assessment methods. The current state of the art in measuring treatment satisfaction is incomplete, and the existing measurement is insufficient. Here, the definition, conceptualisation, application, and methodological issues associated with measurement of treatment satisfaction in GORD are reviewed. Treatment satisfaction may be important for differentiating among GORD treatments, and for monitoring patient outcomes in clinical practice.

The impact of gastroesophageal reflux disease on quality of life

BACKGROUND

Quality of life as a medical endpoint has become an important measure in clinical research.

METHODS

In this article, we review the recent literature that has examined the impact of gastroesophageal reflux disease (GERD) and its treatment of quality of life.

RESULTS

The increasing interest in measuring patients' quality of life as an outcome reflects an increasing awareness that traditional physiological endpoints often do not correlate well with patients' functional status, general well-being, and satisfaction with therapy. It has been shown that GERD has a significant impact on patients' quality of life; therefore, improvement of quality of life is one of the major goals of GERD treatment. This can be achieved by medical as well as surgical treatment.

CONCLUSION

In addition to the patients' perspective, quality of life is one of the major endpoints in medical research that will help provide more selective treatment regimens for our patients.

The outcome of laparoscopic antireflux surgery in relation to patients' subjective degree of compliance with former antireflux medication

It is well known that several patient-related factors are able to affect the surgical outcome such as quality of life or symptom relief after laparoscopic antireflux surgery. The aim of the current study was to evaluate and compare surgical outcome up to 1 year after laparoscopic antireflux surgery in relation to patients' subjective degree of compliance with former antireflux medication. Based on a three-level grading of subjective compliance with primary antireflux medication, a total of 140 patients undergoing antireflux surgery were divided into three subgroups: group 1/TC (totally compliant; n = 60), group 2/PC (partially compliant; n = 49); and group 3/NC (noncompliant; n = 31). Gastrointestinal Quality of Life Index (GIQLI), satisfaction with surgery, and the subjective degree of dysphagia as well as traditional outcome data (e.g., DeMeester score, lower esophageal sphincter pressure, side effects) were evaluated in all patients. As a result of surgery, only patients out of group 1/TC (GIQLI, preoperative 86.3 + 9.3 vs. 1 year postoperatively 123.1 + 7.2 points) and group 2/PC (GIQLI, preoperative 94.2 + 8.6 vs. 1 year postoperatively 120.8 + 7.8 points) showed a significant quality of life improvement that remained stable for at least 1 year (P < 0.05-0.01). In contrast, group 3/NC (GIQLI, preoperative 100.2 + 6.1 vs. 1 year postoperatively 117.2 + 9.8 points) patients had no significant quality of life improvement and patient satisfaction with surgery was less good when compared with that of the other groups. In these patients, also the subjective degree of postoperative dysphagia was significantly (P < 0.05-0.001) higher during the 1-year follow-up when compared with patients from group 1/TC or group 2/PC. A total of 42% of group 3/NC patients reported surgical side effects, whereas only 3% from group 1/TC and 10% from group 2/PC stated to be affected by any new symptoms (P < 0.0001). None of group 1/TC or group 2/PC patients suffered from recurrent symptoms or underwent laparoscopic reoperation. Of group 3/NC, a total of four patients (13%) needed any kind of additional intervention in relation to antireflux surgery (reoperation, n = 3; pneumatic dilatation, n = 1). There were no significant differences between the three groups when postoperative values of esophageal manometry and 24-hour pH monitoring were compared. What the current study does show is that the efficacy and the surgical outcome after laparoscopic antireflux surgery partly depends on the subjective degree of patient compliance with primary antireflux medication. Patients with no compliance in relation to former antireflux medication should generally not be refused antireflux surgery. But these patients should be evaluated with great care before surgery and should also be informed that surgical outcome may be affected in several aspects.

On-demand proton pump inhibitor therapy in patients with gastro-oesophageal reflux disease

On-demand therapy is an established modality in long-term therapy with histamine-2-receptor antagonists, in cases of mild non-erosive gastro-oesophageal reflux disease. In the literature, only a few studies have specifically addressed the problem of proton pump inhibitors on-demand treatment. The evidence, so far, available suggests that this might be an effective modality of long-term treatment in the majority of patients with non-erosive gastro-oesophageal reflux disease. This treatment modality appears to be the most cost-effective and the best tolerated medical regimen for gastro-oesophageal reflux disease. It also seems to be able to restore the impairment of health-related quality of life due to gastro-oesophageal reflux disease symptoms. Although the current standard of care for patients with non-erosive gastro-oesophageal reflux disease is maintenance therapy with daily administration of a proton pump inhibitor agent, on-demand therapy, with the same drug, may be a reasonable long-term choice. The ideal proton pump inhibitors for such treatment will be those with a more rapid onset of action, more profound acid inhibition, more predictable therapeutic effect and less drug-drug interactions. Newer proton pump inhibitors, like esomeprazole, the S-chiral isomer of omeprazole, are promising drugs for on-demand treatment of gastro-oesophageal reflux disease.

Gender differences in the symptoms and physical and mental well-being of dyspeptics: a population based study

PURPOSE

To compare women and men with dyspepsia in terms of symptoms, physical and mental well-being and the relationships between individual symptoms and well-being.

METHODS

A cross-sectional random telephone survey of 2300 Australians identified 748 people with dyspepsia who were interviewed regarding the number, types and severity of symptoms and physical (PCS) and mental well-being (MCS) measured by the SF-12.

RESULTS

There were no significant gender differences in number or average severity of symptoms. Bloating, nausea, and early satiety were significantly more frequent among women; food regurgitation and heartburn in men. Dyspeptics (PCS = 47.1, MCS = 46.0) had poorer physical (p < 0.001) and mental well-being (p < 0.001) than did non-dyspeptics (PCS = 53.5, MCS = 55.3). Among dyspeptics, women (PCS = 46.4, MCS = 44.7) had poorer physical (p < 0.05) and mental well-being (p < 0.001) than males (PCS = 47.9, MCS = 47.5). Some symptoms were associated with low well-being for both sexes e.g. nausea. For women retching was related to poor physical well-being, and food regurgitation, dysphagia. bloating and epigastric pain to poor mental well-being. Among men epigastric pain and heartburn were associated with poor physical well-being, acid regurgitation with poor mental well-being, and vomiting with both.

CONCLUSIONS

Dyspeptics report poorer physical and mental well-being than do non-dyspeptics. The difference between groups is greater for mental well-being, especially among women. Both physical and social factors may contribute to gender differences.

Analysis of medical compliance in gastro-oesophageal reflux disease patients referred to pre-surgical examination

BACKGROUND

Despite potential of modern pharmacotherapy to control gastro-oesophageal reflux disease and also to improve patients' quality of life, an efficient long-term management always depends on patients compliance with medication.

AIMS

To evaluate and analyse potential aspects of compliance or non-compliance with medical and clinical prescriptions in a selected group of gastro-oesophageal reflux disease patients referred to pre-surgical examination because of persistent or recurrent symptoms.

PATIENTS

A total of 182 gastro-oesophageal reflux disease patients have been divided by patient rating to 3 different subgroups: group 1/TC consisted of patients who subjectively stated to be totally compliant (n=71; 39%); group 2/PC of patients with partial compliance (n=65; 36%), and group 3/NC consisted of patients with non-compliance (n=46; 25%) in relation to the prescriptions of their doctor taking care of their treatment.

METHODS

All patients have been asked for potential aspects of compliance or non-compliance. The following aspects have been analysed: understandable medical prescription, information about gastro-oesophageal reflux disease, subjective severity of gastro-oesophageal reflux disease-related symptoms, severity of disease, side-effects of medication, general rejection of medication, multi-medication, patient age and sex, quality of life, and a specific construct of personality (health locus of control).

RESULTS

Significant differences could be calculated between patients' age and gender showing that female and elderly patients are more compliant with medication. Group 1/TC patients suffered from a significantly longer period of symptoms and received medication for a longer period when compared to the other groups. Quality of life was impaired in all patients but patients in group 3/NC had a significantly better quality of life than patients in group 1/TC. The leading aspects for total compliance were: an understandable medical prescription (95%), high severity of perceived symptoms (76%) and of disease (88%). The major factors in group 2/PC patients have been unclear information about gastro-oesophageal reflux disease (41%), mild severity of perceived symptoms (59%), low severity of disease (30%), and a general rejection of medical treatment (21%). General rejection of drug treatment has been the major factor in group 3/NC patients (80%) which can be viewed in relation to patients' personality

CONCLUSION

Compliance or non-compliance in this selected group of patients depended on several factors such as information, subjective severity of symptoms, severity of disease but, in addition, on patients' personality Therefore, new strategies for compliance with long-term treatment in gastro-oesophageal reflux disease patients should be discussed.

On-demand and intermittent therapy for gastro-oesophageal reflux disease: economic considerations

Since gastro-oesophageal reflux disease (GORD) is a prevalent condition characterised by frequent relapses, long-term costs of management for this disease are high. Thus, strategies to decrease resource expenditures without impairing patient quality of life are desirable. On-demand therapy (one-dose when symptoms occur) and intermittent therapy (short course of medication when symptoms occur) are attractive since pharmaceutical expenditures may be decreased, and many patients self-employ this strategy. The purpose of this paper was to examine the economic implications of on-demand or intermittent therapy for GORD. A review of selected studies evaluating medication suitable for on-demand or intermittent administration was performed. A complete search for published studies on the cost effectiveness of on-demand or intermittent therapy for GORD was conducted, and the results discussed in detail. Antacids, alginates, topically active agents, histamine(2)-receptor antagonists, and proton pump inhibitors have all demonstrable efficacy compared with placebo when administered on-demand. Proton pump inhibitors constitute the most effective pharmacological means to treat GORD. Although step-up strategies initially using less potent medication may decrease resource use, cost-effectiveness analysis illustrates that on-demand or intermittent therapy with proton pump inhibitors may be reasonable options. Further work that defines quality of life and patient preferences associated with GORD may allow for proper allocation of resources for the management of this condition.

Epidemiology and natural history of reflux disease

Gastro-oesophageal reflux disease (GORD) is a highly prevalent condition in Western countries; at least 20% of the population have weekly symptoms. The incidence appears to be rising in the West and in some developing countries. Heartburn, based on a carefully elicited history, is reasonably specific for identifying GORD if it is a predominant complaint. Symptoms, however, appear to correlate poorly with oesophagitis; hence, severe symptoms do not indicate there is greater oesophageal damage. Only one-third to one-half of patients with GORD undergoing endoscopy have oesophagitis. GORD is usually a chronic disease but one-third may lose their symptoms over time. An ill-defined subset of patients over time may progress to develop abnormal acid exposure or oesophagitis, or both, when none existed at baseline. GORD has a significant negative impact on quality of life to the same degree as other chronic medical conditions, but impairment in quality of life is independent of oesophagitis.