Gastroesophageal reflux disease (GERD)

Alan Cutler MD: We see the patient, we take a history, and we make a presumptive diagnosis of reflux disease. At that point, we initiate a proton pump inhibitor. Then the patient comes back to see us: if they're better, it was GERD and we've treated it.

If they don't get better, we generally do an endoscopy. We may or may not find anything through endoscopy. If we find, say, reflux esophagitis with erosions, we increase the proton pump inhibitor.

If we don't see anything, we may still suspect reflux disease, double the dose of the proton pump inhibitor and follow them up. If they continue to do poorly, and we're having difficulty establishing a diagnosis, it's at that time that we do a 24-hour pH probe. This will determine whether acid is refluxing up into the esophagus and if this refluxate episode correlates with the time of the patient's complaints.

Lifestyle modifications always have a place in reflux disease. We tell patients to avoid certain foods: chocolate, fried foods, tomato-based products. We tell them to eat multiple small meals, rather than one large meal. We tell them not to eat three to four hours before going to bed.

These maneuvers, however, will not control significant reflux disease. And the patients who come to a gastroenterologist are well beyond mild disease. They like to hear these recommendations, though. And they love to get that sheet of paper with the written recommendations to take home and show their friends.

When I treat reflux disease, I step into therapy with a proton pump inhibitor. If I start a patient at BID dosing [Editor's note: 'bis in die', Latin for 'twice a day'] of a proton pump inhibitor, I then may step them down to once-a-day therapy. I will occasionally try and get them off the proton pump inhibitor and may give them either PRN proton pump inhibitors or H2 blockers as a step-down therapy.

I never do step-up therapy. Step-up therapy would be to start with antacids, then go to H2 blockers, then move to a proton pump inhibitor.

Alan Cutler MD: Proton pump inhibitors are the primary therapy used to control and maintain reflux disease. H2 blockers have been used, but in up to 30% of patients, the H2 blockers become ineffective, because the body up-regulates or tachyphylaxis occurs and the drugs become ineffective.

Malcolm Robinson MD: Proton pump inhibitors continue to work week after week, month after month, year after year, and patients who respond initially are likely to continue to respond indefinitely. H2 receptor antagonists, on the other hand, when used chronically and continuously, unfortunately can develop tolerance, tachyphylaxis; and these drugs, therefore, may cease to work after varying periods of time of continuous therapy. In patients who are successfully able to take intermittent therapy, tachyphylaxis is less a problem with the H2 receptor antagonists, and of course not a problem at all with the proton pump inhibitors.