Step-down management of gastroesophageal reflux disease

Background & Aims: As the economic burden of gastroesophageal reflux diseas e (GERD) is largely weighted to maintenance as opposed to initial therapy, switching from more potent to less expensive medication once symptoms are a lleviated (step-down therapy) may prove to be most cost-effective. This stu dy aimed to prospectively evaluate the feasibility of step-down therapy in a cohort of patients with symptoms of uncomplicated GERD. Methods: Patients whose GERD symptoms were alleviated by proton pump inhibitors (PPIs) were recruited from outpatient general medicine clinics. After baseline demograp hic and quality of life information were obtained, PPIs were withdrawn from subjects in a stepwise fashion. Primary outcome was recurrence of symptoms during follow-up that required reinstitution of PPIs. Secondary outcomes i ncluded changes in quality of life and overall cost of management. Predicto rs of nonresponse to step-down were assessed. Results: Seventy-one of 73 en rolled subjects completed the study. Forty-one of 71 (58%) were asymptomati c off PPI therapy after 1 year of follow-up. Twenty-four of 71 (34%) requir ed histamine 2-receptor antagonists, 5/71 (7%) prokinetic agents, 1/71 (1%) both, and 11/71 (15%) remained asymptomatic without medication. Quality of life did not significantly change, whereas management costs decreased by 3 7%. Multivariable analysis revealed younger age and a dominant symptom of h eartburn to predict PPI requirement. Conclusions: Step-down therapy is succ essful in the majority of patients and can decrease costs without adversely affecting quality of life.