GERD treatment guidelines developed for Filipino physicians

The Philippine Society of Gastroenterology (PSG) has completed the development of treatment guidelines for gastroesophageal reflux disease or GERD, a bothersome condition whose prevalence in the country is increasing.

PSG president Dr. Peter P. Sy said: “While the bothersome symptoms associated with GERD are common reasons for clinic visits among Filipino patients, there are currently no clinical practice guidelines for GERD treatment in the Philippines. As such, we developed the Philippine Consensus Guidelines for the Management of Gastroesophageal Reflux Disease.”

“In crafting these consensus guidelines, our goal was to address the need of Filipino primary care physicians and specialists for updated, evidence-based guidance in the management of GERD,” said Dr. Jose D. Sollano, PSG past president and lead convenor of the GERD Consensus Development Group of the PSG which developed the guidelines. “Moreover, the government’s Universal Health Care program may soon require country-specific guidelines for GERD diagnosis and management,” he added.

Faulty valve

After every meal, millions of tiny pumps in the stomach—proton pumps—produce the acid that helps digest food. At the bottom of the esophagus (the tube that carries food from the mouth to the stomach) is a ring of muscle called the lower esophageal sphincter (LES). The LES opens between the esophagus and stomach to allow food and liquids to enter the stomach.

If the valve doesn’t close tightly, or if it opens too often, stomach acid can move up into the esophagus. This condition is called gastroesophageal reflux (GER).

Most patients will not complain of symptoms. However in some patients, GER can cause troublesome symptoms like recurrent heartburn, sour taste in the mouth (acid regurgitation), chronic sore throat, hoarseness, sensation of a lump in the throat and chest pain.

“Occasional GER is common and does not necessarily mean a person has GERD. However, persistent GER that results in the annoying symptoms just mentioned is considered GERD,” explained Dr. Joseph Bocobo, PSG past president and member of the GERD Consensus Development Group.

Diagnosis

The consensus guidelines define GERD as “a condition resulting from the recurrent backflow of gastric contents into the esophagus and adjacent structures causing troublesome symptoms and/or tissue injury.”

Local primary care physicians can diagnose GERD in the clinic if the typical symptoms of acid regurgitation and/or heartburn are present. In this setting, the consensus guidelines do not consider an upper endoscopy as absolutely necessary to establish a diagnosis of GERD. Upper endoscopy is a procedure that uses an endoscope (a small, flexible tube with a light source) to see the lining of the upper gastrointestinal tract.

For patients who present with chest pain, even if suspected to be GERD-related, the consensus guidelines recommend appropriate cardiovascular risk assessment before starting treatment to ensure patient safety. This ensures that a heart attack is not misdiagnosed as GERD. Such a cardiovascular risk assessment should include, at a minimum, history and physical examination, 12-lead electrocardiogram (ECG) and Troponin I (a blood test that indicates a heart attack in people with chest pain).

Untreated, GERD can cause complications more serious than the bothersome symptoms mentioned previously. Erosive esophagitis develops when the esophagus is damaged by continued exposure to stomach acid. Barrett’s esophagus is a serious complication of longstanding GERD involving profound changes in the nature of the tissue normally lining the esophagus. It increases the risk of cancer of the esophagus.

Management of GERD

GERD can be managed through lifestyle modification and drug therapy. Antireflux surgery may only be required in patients who continue to have severe symptoms, erosive esophagitis or disease complications despite adequate drug therapy.

Proton pump inhibitors, also known as PPIs, are the first-line treatment for GERD. They reduce the production of acid in the stomach. Less stomach acid means less irritation of the esophagus if gastric reflux occurs, thereby allowing the esophagus to heal.

According to the consensus guidelines, “Standard dose PPI once daily for 8 weeks, taken 30 minutes before breakfast is the cornerstone of GERD therapy.”

Even with patient compliance, inadequate symptom control especially at night may still occur due to the failure of PPIs to provide 24-hour acid control. Dexlansoprazole, a novel PPI with Dual Delayed Release (DDR) formulation, was recently made available by Takeda Pharmaceutical (Philippines) Inc. to address this gap. The once-a-day capsule provides 24-hour control of acid production for round-the-clock symptom relief and improved sleep. Unlike other PPIs that must be taken 30 to 60 minutes before a meal for optimal efficacy, Dexlansoprazole can be taken anytime with or without food. This flexible dosing increases patient compliance and enhance treatment success.

When symptoms still relapse after the recommended standard GERD treatment, on-demand or intermittent PPI therapy is suggested for nonerosive reflux disease (NERD) while continuous PPI treatment is recommended for moderate to severe erosive esophagitis.

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