A PROKINETIC APPROACH TO TREATMENT OF GASTROESOPHAGEAL REFLUX DISEASE

Currently available medications for gastroesophageal reflux disease (G ERD) vary in mechanisms of action from neutralization or suppression o f gastric acid to improving underlying Antireflux therapy upper gastro intestinal dysmotility, This article reviews the clinical efficacy of pharmacological agents used to treat GERD and provides a rationale for considering a primary prokinetic approach to antireflux treatment whi ch will be applicable to many patients, Treatment trials in acute GERD have demonstrated unexpectedly prolonged maintenance of high esophage al pH with tablet and liquid antacid formulations, However, there are no well-designed placebo-controlled trials of antacids for esophageal mucosal healing. H-2 receptor antagonists (H2RAs) al conventional dose s relieve reflux symptoms in at least 50% of reported series of GERD p atients, and they can also provide endoscopic healing in 27-45% of the cases. Therapy with more potent acid-suppressive agents such as proto n pump inhibitors (PPIs) may lead to improved symptomatic relief and t o superior healing compared with H2RA therapy, especially in those pat ients with more advanced erosive esophagitis, Promotility agents, part icularly cisapride, offer symptom relief and healing rates which are q uite similar to standard H2RA treatment. GERD tends to be a chronic an d relapsing condition. Cisapride has been shown to be quite effective in maintaining remission in GERD patients, including endoscopic remiss ion in the lesser degrees of esophagitis, This may be accomplished wit h relatively low and cost-effective dosing in many individuals, For th e small proportion of patients who manifest severe grades of esophagit is, PPI therapy is associated with lower relapse rates than either H2R A or prokinetic treatment. Overall, a strong case can be made for the empirical selection of promotility therapy for the large numbers of GE RD patients who do not have documented severe erosive disease.