PHARMACOLOGICAL MANAGEMENT OF GASTROESOPHAGEAL REFLUX DISEASE

Gastro-oesophageal reflux disease (GORD) ranges from episodic symptoma tic reflux without oesophagitis to severe oesophageal mucosal damage, such as Barrett's metaplasia or peptic stricture. The multifactorial p athogenesis of GORD prevents medical cure of the disease. GORD is a ch ronic disease with a high tendency to relapse, requiring a long term t reatment strategy in practically all patients. Complete healing of all mucosal lesions is not necessarily the aim of treatment in all patien ts. In milder forms of reflux disease, symptom relief is the most impo rtant goal. Many patients with mild GORD do well on symptomatic self-c are with antacids and/or alginate. In addition, lifestyle changes shou ld be advised to all patients: these improve symptoms and enhance the efficacy of therapy. In the acute treatment of GORD the prokinetic dru g cisapride has been shown to be effective in relieving symptoms and h ealing grade I to II oesophagitis. Cisapride decreases symptomatic and endoscopic relapse in patients with mild GORD. Histamine H-2-receptor antagonists are effective in relieving reflux symptoms in about 50% o f patients, but with regard to healing, H-2-antagonists appear to be m ainly effective in grades I and II and not in higher grades of oesopha gitis. Maintenance treatment with H-2-antagonists is mainly symptomati cally effective in patients with mild GORD. Proton pump inhibitors (PP Is) provide significantly higher healing rates of reflux oesophagitis than H-2-antagonists, even in the more severe cases of oesophagitis an d Barrett's ulcers. PPIs are also effective in patients with oesophagi tis refractory to treatment with H-2-antagonists. PPIs have become the drugs of first choice in healing of all patients with more seven form s of reflux oseophagitis, and increasingly also for patients with mild er forms of oesophagitis, certainly those who fail to respond to other drugs. In maintenance treatment of CORD, PPIs are the most effective drugs, offering the possibility of keeping nearly all patients in remi ssion with adjusted doses. Current patient data of up to 5 years indic ate the safety of this strategy for this period, but the exact consequ ences of strong acid inhibition over a longer period still have to be clarified. At present, all but a few patients with GORD can be managed adequately by medical therapy.