Maintenance Therapy

Û Many patients with GERD experience relapse if medication is withdrawn, and long-term maintenance treatment is required in such patients.1 Candidates for maintenance therapy include patients whose symptoms return once therapy is discontinued or decreased, patients with a history of esophagitis healed by PPIs, patients with complications such as Barrett's esophagus or strictures, and perhaps patients with atypical symptoms. In some patients, the dose of acid-suppressing therapy may be titrated to the lowest dose that controls symptoms.

The goal of maintenance therapy is to improve quality of life by controlling symptoms and preventing complications. These goals cannot generally be achieved by decreasing the dose or switching to a less potent acid-suppressing agent. Most patients

require standard doses to prevent relapses. Patients should be counseled on the importance of complying with patient-specific lifestyle changes and long-term maintenance therapy to prevent recurrence or worsening of disease.

The H2RAs may be effective maintenance therapy for patients with mild disease.6 The PPIs are first choice for maintenance treatment of moderate-to-severe GERD.29 A short course of "on-demand" therapy maybe appropriate in patients with symptomatic esophageal syndromes without esophagitis when symptom control is the primary outcome of interest.2 With on-demand therapy, patients take the medication only when symptoms occur. Antacids have the fastest onset and may be used in combination with an H2RA or PPI for "on-demand" symptom relief. However, patients with a history of esophagitis and/or complications should be maintained on standard daily doses of PPIs for maximum benefit. PPIs significantly decrease the incidence of dysplasia in patients with Barrett's esophagus for over 20 years.30

Long-term use of higher PPI doses is not indicated unless the patient has complicated symptoms, has erosive esophagitis per endoscopy, or has had further diagnostic evaluation to determine degree and frequency of acid exposure. Antireflux surgery and endoscopic therapies may be viable alternatives to long-term drug use for maintenance therapy in selected patients.

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