Gastroenterology

Gastroenterology

Volume 121, Issue 5, November 2001, Pages 1095-1100
Gastroenterology

Clinical Research
Step-down management of gastroesophageal reflux disease,☆☆

https://doi.org/10.1053/gast.2001.28649Get rights and content

Abstract

Background & Aims: As the economic burden of gastroesophageal reflux disease (GERD) is largely weighted to maintenance as opposed to initial therapy, switching from more potent to less expensive medication once symptoms are alleviated (step-down therapy) may prove to be most cost-effective. This study 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 After baseline demographic and quality of life information were obtained, PPIs were withdrawn from subjects in a stepwise fashion.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 included changes in quality of life and overall cost of management. Predictors of nonresponse to step-down were assessed. Results: Seventy-one of 73 enrolled subjects completed the study. Forty-one of 71 (58%) were asymptomatic off PPI therapy after 1 year of follow-up. Twenty-four of 71 (34%) required 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 37%. Multivariable analysis revealed younger age and a dominant symptom of heartburn to predict PPI requirement. Conclusions: Step-down therapy is successful in the majority of patients and can decrease costs without adversely affecting quality of life.

GASTOENTEROLOGY 2001;121:1095-1100

Section snippets

Materials and methods

The population studied was composed of outpatients in the general medicine clinics at the Veterans Administration (VA) Albuquerque Regional Medical Center. A list of patients in whom PPIs were prescribed was generated through the pharmacy module of VISTA, the computer database of the medical center. Because PPIs were also prescribed for non-GERD indications, such as ulcer disease or Helicobacter pylori eradication, only those prescriptions filled for greater than 8 weeks were considered. The

Results

Three hundred seventy-six patients were identified as having been prescribed PPIs for 8 weeks or longer from our medical center. One hundred fifty-five consecutive patients were evaluated in the GERD clinic. Of these, 82 were excluded (Table 1); the largest group of patients excluded were those still symptomatic despite PPI use.

. Excluded patients

Symptomatic despite PPI therapy
 Heartburn or acid regurgitation7
 Dyspepsia22
Peptic stricture17
Extraesophageal GERD11
Anemia or occult GI bleeding10
PPI use

Discussion

This study of patients with reflux symptoms treated with PPIs in a primary care setting revealed that more than half could be maintained in remission without PPI therapy. Twenty-seven percent required no medication to treat their reflux symptoms, and the remaining 73% in whom step-down was successful required less expensive forms of anti-GERD therapy. Younger subjects required PPIs to alleviate recurrent symptoms more often than older subjects. A dominant symptom of heartburn also predicted the

References (26)

  • A Eggleston et al.

    Cost-effectiveness of treatment for gastro-oesophageal reflux dis-ease in clinical practice: a clinical database analysis

    Gut

    (1998)
  • LJ Hixson et al.

    Current trends in the pharmacotherapy for gastroesophageal reflux disease

    Arch In-tern Med

    (1992)
  • S Sridhar et al.

    Clinical economic review: cost-effectiveness of treatment alternatives for gastro-oesophageal reflux disease

    Aliment Pharmacol Ther

    (1996)
  • Cited by (0)

    Address requests for reprints to: John M. Inadomi, M.D., VA Ann Arbor Medical Center (111-D), 2215 Fuller Road, Ann Arbor, Michigan 48105. e-mail: [email protected]; fax: (734) 761-7549.

    ☆☆

    Supported by a Junior Faculty Development Award from the American College of Gastroenterology (to J.M.I.) and by a grant from the Centers for Disease Control (to A.S.).

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