Nonpharmacologic Therapy

Nonpharmacologic treatment of GERD includes patient-specific lifestyle modifications, antireflux surgery, or endoscopic therapies.

Lifestyle Modifications

Although most patients do not respond to lifestyle changes alone, the importance of maintaining these lifestyle changes throughout the course of GERD therapy should be stressed to selected patients on a routine basis. The most common lifestyle changes that a patient should be educated about include: (a) losing weight and (b) elevating the head of the bed if symptoms are worse when recumbent. Elevating the head of the bed about 6 to 10 in. (15-25 cm) with an undermattress foam wedge (not just elevating the head with pillows) decreases nocturnal esophageal acid contact time and should be recommended.4

Other lifestyle modifications should be considered based on the circumstances of the individual patient. These include: (a) eating smaller meals and avoiding meals 3 hours before sleeping, (b) avoiding foods or medications that exacerbate GERD, (c) smoking cessation, and (d) avoiding alcohol.

Patient medications and food histories should be evaluated to identify potential

7 11 12

factors that may exacerbate GERD symptoms (see Table 17-1). ' ' Patients should be monitored closely for symptoms when medications known to worsen GERD are started.

Antireflux Surgery and Endoscopic Therapies

Antireflux surgery or endoscopic therapies offer alternative treatments for refractory GERD or when pharmacologic management is undesirable.

Antireflux Surgery

Surgical intervention is a viable alternative for selected patients with well-documented GERD.1 The goal of surgery is to re-establish the antireflux barrier, to position the LES within the abdomen where it is under positive (intra-abdominal) pressure, and to

close any associated hiatal defect. It should be considered in patients who: (a) fail to respond to pharmacologic treatment; (b) opt for surgery despite successful treatment because of lifestyle considerations including age, time, or expense of medications; (c) have complications of GERD (Barrett's esophagus or strictures); or (d) have atypic-

al symptoms and reflux documented on 24-hour ambulatory pH monitoring. In the latter situation, the benefits of surgery must be carefully weighed against the risks including flatulence, inability to belch, and postsurgery bowel symptoms.

Table 17-2 Therapeutic Approach to GERD in Adults

Patient Presentition

Recommended Treatment Regimen

Comment!

iriijpi'i'E'JttsriX

5>™p1orretc GEHO

Healing of e rCiSr.P «üpfiagitri a healmentof modeiate 10 MivW iylKXHOrt^ <K oo implications

A. Ufafjffe minliftation; <>n pSiie^T-ipKilW;

circumstances PtUS

S. Antacids

» MagnesiunVakuminum hydronlde 30 nV. after meat? and at bMJllnw as pnwdod » Araacid/alglnic acklfGaviscori) 2 tablelsor 15 mLafiet meals and ad bedtime AfoO/titf

C,eaiiefmlir*t«d therapy

• Over-the-counter H .A As (each taken up to twke daily)

ClnnffiirJine JDO ring : jmol»dint 10 mg llifatidine 7i mg Aanrrdine hhj

■ Ouet-lhe-countef Ifl (taken-ones dlaily)

Ofiwpiwsle ZO.lmji A. Lifestyle modifications based on patiem specific Lin umslJhLL't ftUS

Pi i-l^ixdird dOf* 4Cid-flfl{lNMing llifiapy

C Irne^irtifve ^00 n>g

F^rttolidipe XI mr| ftirathrlme iSOmg biMh-lffimj

• PPIs (taken once daily) far 4 to a wieeks; increase to twice daily in palients with inadequate symplom response lt> ijftfj- rl.vrty therm Dexlansoprajolo 50 mg

LonMjprjiKiV» 15 to 30 mg Orm.>pía«)le 20 mg F'jftiofiraKilií JOrfttj flabepiasole 20 mg A. Lifestyle modifications HUB

8, ppis (íatírtonce-tir iwioe dailjO fo A tö »6 wetks (Jeíleíiwpw?1«1^1 r™»

Esomcprazole 2Ol(H0rng UrtMJpfMOle ÍHítUj Omfpraíüle ÍOmg ÜjlKlJfWOlí 20 mfl fanrofiramle W ring

■ If symptoms are unrelieved with Mes:yle changes and o^w-thc tauniicT medications after 2 weeki begin 1fierapy with a standaid dow atmJ-iuHJU.'Hjny agent • AKjoinvyiH iiirHiirirtg irnin'i(l* nrisy accumulate« iwial failure. May need to demMse duw or jvoid

«titiyiTi-COrvwiiiiiüj .iiir.ii ►:)■. may m^d (0 fc>i decreased in patenis with CitI leis than iS mLArirt (based on serum calckim level) > In general, g we 50% of H ,RA dose wilh CrCI less than SO ml/tinm

' Fe« typical syinplonis. deal empirically w1h

■ i.-■ 11ri.b'< : dmy\ l:- ,k id >jli(]|;h".miv; chi'i.ipyy

. Mild otHCJirar« usua«y fc*- Treated effectively with H RA.S. Patients vrtt+i modelati?-1o-Siviff 'syi1iiCiKinHth(3uk)<fiem? i PPI il Initial Therapy. iKympirwni. an* retevi?d. treat iccurences on an ay nettled basis

■ If ".ymptoms recur frequently, consider maintenance iuTapy with the lowest dfcclrne tfuse n Müvt |viE>i?iil v Uf |u ri1 slarKljicJ rlrw-'. fin maintenance therapy

■ May need Id decrease dose of omeprazole, «rtfoefirjjoli, ,in(l IflitWi*wot wilh severe ker impairment. Mo specific recCiTwnppi.Wfcp'i Iväüjbte t4a odjuvfurnl iteeded lb- pamopiazole

■ For atypical symptoms, give a (rial of a PPl or Hfl*

■ If symptoms are relieved, consider maintenance therapy1

■ PPts M? the moit effective maintenance therapy in pjlierHs with atytikal symptoms. ÍOrrilÜkiKd SyrlT(K0ill5, Of diWJW

• Píiíienis not responding Id acid suppressing nhdipy, Indu4in^ ilnWII h pxf snr^m a:ypKal symptoms, may be candidates for antireHlim surgery or endoscopk therapies

GERHíjastior^opíiageai n-ilu« Jisrase: I i.R*, hiistarnine íi^ciJtor jnlagcmist FPI. protun punijj inh.liittv.

Adapted from Williams Olü Schade RR. Gast oesophageal rellux disease, in: DiRroJF. Talbert PL. Yee GC. et al. eds Pharmaootheiapy A ParhophysicJoqic Approach, 7ihed.Mewi York: McGraw-Hill. Ä0S: 560, wilh peimnslon.

Unfortunately, up to 60% of patients still require use of antireflux medications approximately 10 years postsurgery, and surgery is not superior to PPIs in terms of eso-phagitis grade, complications, or quality of life with long-term follow-up.14

Endoscopic Therapies

Three endoscopic approaches to the management of GERD are available.15 They include: (a) application of radiofrequency energy to the LES area (Stretta procedure), (b) endoscopic suturing to produce a plication (Endocinch), and (c) endoscopic injection of a biopolymer at the gastroesophageal junction.1 More studies and experience are needed to determine their exact role in the management of GERD. They cannot currently be recommended for routine use in patients with esophageal GERD syndromes.2

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