Review Article: Acid suppression in the management of gastro-oesophageal reflux disease - an appraisal of treatment options in primary care

Gastro-oesophageal reflux disease (GERD) is one of the most common conditio ns presenting to the primary care physician. Despite progress in understand ing and treatment of the disease, strategies for capitalizing on these adva nces are less well developed. In many practices, H-2-receptor antagonists s till remain the most widely prescribed treatment for GERD, despite the avai lability of the more effective acid-suppressant proton pump inhibitors. This review examines the relative efficacies of acid-suppressant drugs in m inimizing oesophageal acid exposure and outlines the evidence for the super iority of proton pump inhibitors over standard-dose H-2-antagonists in symp tom relief, erosion healing and prevention of relapse in GERD. Current pres cribing patterns and considerations for the general practitioner are also e xamined. The availability and impact of over-the-counter H-2-antagonists on the treatment of GERD and their relative cost-effectiveness vs. proton pum p inhibitors are also addressed. A hierarchy of drug efficacy (full-dose proton pump inhibitor > half-dose p roton pump inhibitor > high-dose H-2-antagonist > standard-dose H-2-antagon ist or prokinetic) applies in principle to all GERD patients, (with or with out oesophagitis). The most effective initial therapy for GERD is also like ly to be the most cost-effective one, if treatment failure leads to higher utilization of medical resources. The application of these recommendations to the management of non-endoscope d GERD, endoscopy-negative GERD and low-grade oesophagitis as well as highe r grade oesophagitis is also reviewed.