An important point to consider when working with patients who may be thought to have refractory gastroesophageal reflux disorder (GERD) is whether the patient in fact has GERD at all, Michael Vaezi, MD, PhD, said during his presentation on managing reflux at the American College of Gastroenterology (ACG) postgraduate course on October 23.

Dr Vaezi is the clinical director of the Division of Gastroenterology, director of the Center for Swallowing and Esophageal Disorders, and professor of medicine at Vanderbilt University.

Proton pump inhibitors (PPIs) remain a highly effective and safe treatment for reflux. Trials have shown that PPIs are more effective in the management of reflux relative to placebo and to histamine-2 receptor blockers (H2RA), Dr Vaezi explained. Patients should be reassured that earlier concerns about risks of long-term PPI use have been largely discounted by research, barring a slight elevation in the risk of enteric infection.

Some therapies, such as bile sequestrants for add-on therapy to PPIs and alginates, have not demonstrated efficacy in trials. But potassium competitive acid blockers (PCABs), such as vonoprazan and tegoprazan, are showing great promise as an alternative to PPIs.

“PCABs are mostly available in Asia now,” Dr Vaezi said, although clinical trials are ongoing in the US. Vonoprazan is not yet approved by the US Food and Drug Administration for the treatment of reflux, but, Dr Vaezi said, “Don’t be surprised if they [PCABs] get approved here.” These therapies have faster onset than traditional PPIs and have a superior mechanism of action, he said. These agents appear safe and help to improve patients’ quality of life.

Lifestyle changes are also important in managing reflux. Patients should be advised to stop smoking, reduce caffeine and alcohol consumption, and particularly, to reduce weight. The latter is the most important step patients can take to help control their reflux, Dr Vaezi said. 

What if PPIs don’t help?  First, Dr Vaezi said, “You need to find out if the patient is actually taking the medication, and how. Assess the dosage, the frequency, and the timing, which is important with PPIs.

“Also consider that the patient may not have reflux at all,” he continued. A mechanical defect may be the cause of symptoms such as bloating, burping, abdominal pain, regurgitation, and dysphagia.

Dr Vaezi shared a case study of a 58-year-old woman with what she described as “bad reflux.” She had suffered with heartburn and regurgitation for years, and also admitted to frequent coughing and bouts of pneumonia as well as sinus infections. The patient was interested in knowing if any endoscopic or surgical procedures could help relieve the reflux.

“The cough and pneumonia are clues that this is probably not reflux,” Dr Vaezi said. In this case, the patient actually had achalasia; the retained food caused the heartburn and regurgitation.

“The number 1 misdiagnosis of reflux is with patients who actually have achalasia,” he stated. H further cautioned against using the term “refractory GERD” and prefers “refractory symptoms,” making it clear that the symptoms may be attributable to a cause other than reflux.

In summary, Dr Vaezi said, “Post empiric therapy reflux, if the patient improves you should taper the patient to the lowest dose of acid suppression therapy. Patients should be on the lowest dose that controls their symptoms.”

And if the patient does not improve, Dr Vaezi continued, “Discontinue acid suppression. Search for alternative diagnoses and look for mechanical defects” to ensure that the right diagnosis is made before continuing with other treatments for reflux.

--Rebecca Mashaw

Vaezi, MF. Management of reflux: Effective use of PPIs and beyond. Presented at the American College of Gastroenterology Postgraduate Course. October 23, 2021.