Medical therapy for GERD works well at controlling GERD symptoms and healing esophageal injury. Most patients tolerate the medications very well, with few side effects. However, medical therapy has drawbacks: failure to control non-acid reflux, requirement for increased dosing, increased risk of side effects including osteoporosis, and cost.
Techniques to correct reflux have been demonstrated to be as effective, if not more effective, than medical therapy. However many patients are not even aware that alternatives to medical therapy exist.
Increasingly physicians are recognizing that reflux persists despite taking anti-acid medication. This non-acid reflux causes problems also.
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Although refluxed acid is the most injurious compound in stomach contents, there are, as one of my medical colleagues says, 'many other things in stomach juice that I wouldn't want to put in my eye.' Non-acid reflux can cause persistent heartburn and reflux sensation. Non-acid reflux has been tied to chronic cough, hoarseness, worsening of asthma, persistent vocal cord irritation. Since it has only been in the past 20 years that stomach acid could be almost completely eliminated by medication, we are just now beginning to understand the degree to which non-acid reflux occurs and what problems it incurs.
Many patients require ever-increasing doses of medication or switching medications in order to keep symptoms under control. We not uncommonly see patients who have been tried on many different PPIs with many different dose ranges who have persistent, uncontrolled symptoms of GERD. Many of these patients were never informed that procedures to repair the anti-reflux valve and eliminate reflux existed.
Proton Pump Inhibitors (PPIs) have been the most commonly used medication to treat GERD in the past 20 years. Nexium, Prilosec (omeprazole), Prevacid, Protonix, Aciphex, and Zegerid are trade names of the most common PPIs. Although PPIs have an excellent safety record overall, a 2006 study published in the Journal of the American Medical Association showed a significant increase in the risk of osteoporosis in patients over 50 years of age who were taking PPIs for more than a year. Patient who took twice a day PPIs were at nearly a three-fold risk of developing a hip fracture if they took medication more than 1 year.
The American Academy of Family Physicians has a bullletin on the use of PPIs. In that publication they outline potential side effects of PPIs including when other medication dosing should be altered by the addition of PPIs. Although the list is fairly short compared to many other medications, there are still potential interactions of which many patients are unaware.
Additionally, cost is becoming an issue for more and more patients. Nexium, which is probably the most potent acid-suppressive medication available, is a purified form of Prilosec, which is now available over the counter. Some insurance prescription programs have stopped covering Nexium for this reason - and patients are left to pay for Prilosec over-they-counter at great cost to them.
In general, if one pill a day controls heartburn and reflux symptoms, the patient has no upper-airway symptoms that are due to GERD, and the patient takes supplemental calcium and has bone density monitored, and the medication is affordable, it seems reasonable to say that PPI therapy is the safest way to manage that patient's GERD.
However, if:
-increasing doses are needed, or
-patients are having to switch medications because one is not working,or
-heartburn, reflux, or other GERD symptoms persist despite taking medication, or
-upper airway or laryngeal symptoms are due to non-acid reflux, or
-the patient is already at high risk for osteoporosis,
then strong consideration should be given to procedures to repair the antireflux valve - the Laparoscopic Fundoplication or the EsophyX Transoral Incisionless Fundloplication.
