George, a 78 year old male, comes in to your office for an initial visit as his previous physician has retired. His chronic medical issues are managed and stable, but he has been having increasing heartburn. He takes an antacid as needed but is not finding this to be sufficient.
Issue: What does the evidence say about investigation and management of George’s symptoms?
Gastroesophageal Reflux Disease (GERD) is defined as symptoms or complications resulting from the reflux of gastric contents into the esophagus, the oral cavity (including larynx), or lung.[i] A number of studies have identified that GERD is the most common gastrointestinal disorder encountered in primary care practice.[ii] [iii] Heartburn and regurgitation are classic and common symptoms; chest pain may also be a presenting symptom. Where chest pain is present, it is critical to exclude cardiac causes of pain before ascribing the pain to GERD. Extra-esophageal manifestations include chronic cough, asthma and laryngitis. Atypical symptoms include dyspepsia, epigastric pain, nausea, bloating and belching, though these are symptoms also seen in other conditions. In the elderly, atypical and extra-esophageal symptoms may be more likely to be the presenting complaint.
Epidemiology: The incidence of GERD is shown to be significantly higher with aging. A population-based study has demonstrated that annually, incidences of GERD affect 0.82% of men age 70-79 and 0.66% of women age 70-79. In comparison, in men and women age 20-29, the incidence of GERD is much lower at 0.40% and 0.36%, respectively.[iv] Studies have shown that frequency and duration of esophageal acid exposure, and severity of esophagitis in those with reflux esophagitis increases with age. On the other hand, the prevalence of symptoms does not clearly increase with age.[v] When symptoms do appear, they tend to be more severe, and have a greater impact on quality of life. Aggravating factors for GERD include medications that reduce lower esophageal sphincter tone, higher frequency of the presence ofhiatal hernia, impaired esophageal peristalsis, decreased saliva volume and bicarbonate concentration, and postural changes related to osteoporosis andparaspinal muscle strength. Obesity is a major risk factor. There is some evidence to suggest that waist circumference and waist-to-hip ratio correlates more strongly with risk for erosive esophagitis than does body mass index (BMI).
Alarm symptoms such as anemia,dysphagia,odynophagia and vomiting may present more frequently in the elderly. Weight loss may or may not be present. Where alarm symptoms are identified, further investigation is required. Upper endoscopy is the recommended investigation. With the elderly, endoscopy may also be recommended for individuals who present with atypical symptoms, extra-esophageal symptoms or a previous history of GERD.[vi]
Treatment: While lifestyle modifications are typically recommended, there is limited evidence for broad application of these measures. Weight loss has been shown to be beneficial for individuals with recent weight gain or those with a BMI >25. Elevation of the head of the bed and avoidance of late evening meals, particularly with high fat content, has shown to be beneficial for individuals with nocturnal symptoms or sleep disturbance. Avoidance of food triggers such as chocolate, caffeine, citrus foods, spicy foods, carbonated beverages, etc., has been shown to be beneficial only if an individual can identify a specific trigger. Routine avoidance of these potential triggers has not been shown to be an effective strategy in reducing the frequency, severity or risk for complications.[vii]
For individuals who have only typical symptoms, a presumptive diagnosis can be made and a trial of a proton pump inhibitors (PPI) is indicated. There are no clear differences between PPIs in terms of symptom relief or healing of erosive esophagitis.[viii] The PPI is dosed once a day and the trial should typically be four to eight weeks in duration. For best effect, PPIs other than dexlansoprazole should be administered 30-60 minutes before the first meal of the day. There is limited data to support switching between agents and no data to support multiple switches. A reason for a switch may be related to side effects such as headache, rash, diarrhea or constipation, nausea or abdominal pain. Dose reduction may also be effective in resolving some of these side effects.
For individuals with typical symptoms of GERD who also have potential extra-esophageal symptoms, a similar PPI trial can be recommended. The trial is intended to treat the typical symptoms; there is limited evidence of impact on extra-esophageal symptoms. For example, although studies have demonstrated improvement in some asthma outcomes, a meta-analysis suggested only a small improvement in peak expiratory flow rate of uncertain clinical significance[ix]. Symptoms more likely to respond to PPI therapy include epigastric pain, early satiety and belching. Nausea and vomiting are less likely to improve.[x]
Other agents such as histamine receptor blockers or antacids may be helpful in relieving mild and/or transient reflux symptoms. Antacids have a relatively short duration of action and their use can be associated with significant side effects. Promotility agents are sometimes used but without strong evidence to support this practice.
The most recent American recommendations suggest that if an initial trial of a PPI is unsuccessful in managing symptoms, further investigation would be worthwhile. Recommendations from TOP Guidelines (2009) suggest that an additional four-week trial of twice daily PPI use would also be a reasonable approach.[xi] For individuals who re-develop symptoms after a successful initial trial of therapy, or for those with complications including erosive esophagitis or Barrett’s esophagus, maintenance therapy using the lowest effective dose, which could include on-demand therapy, is recommended.[xii] The risk for Vitamin B12 deficiency with longer term use has not been demonstrated in the general population, though case studies suggest an association in the elderly. Chronic use may increase the risk for infection, such as with Clostridium difficile, though the association has not yet been proven.
[i] Katz P, Gerson L, Vela M. Guidelines for the Diagnosis and Management of Gastroesophageal Reflux Disease. Am J Gastroenterol 2013;108:308-328.
[ii] Shaheen NJ, Hansen RA, Morgan DR, et al. The burden of gastrointestinal and liver diseases, 2006. Am J Gastroenterol 2006;101:2128-38.
[iii] Tougas G, Chen Y, Hwang P, Liu M, Eggleston A. Prevalence and Impact of Upper Gastrointestinal Symptoms in the Canadian Population: Findings from the DIGEST Study, Am J Gastroenterol 1999;94:2845-54.
[iv] Ruigomez A, Garcia Rodriguez L, Wallander M et al. Natural history of gastroesophageal reflux disease diagnosed in general practice. Aliment Pharmacol Ther 2004;20(7):751-760.
[v] Soumakh A, Schnoll-Sussman F, Katz P. Reflux and Acid Peptic Diseases in the Elderly. Clin Geriatr Med 2014;20:29-45.
[vi] Ibid v
[vii] Ibid i
[viii] Gralnek I, Dulai G, Fennerty M et al. Esomeprazole vs. other proton pump inhibitors in erosive oesophagitis: a meta-analysis of randomized controlled trials. Clin Gastroenterol Hepatol 2006;4:1452-1458.
[ix] Chan W, Chiou E, Obstein K et al. The efficacy of proton pump inhibitors for the treatment of asthma in adults: a meta-analysis. Arch Int Med 2011;171:620-629.
[x] Gerson LB, Kahrilas PJ, Fass R. Insights into gastroesophageal reflux disease-associated dyspeptic symptoms. Clin Gastroenterol Hepatol 2011; 9:824-833.