How do we offer clinical relief to patients with gastro-oesophageal reflux disease?

In gastro-oesophageal reflux disease (GORD), the majority of patients are endoscopy negative. However, symptoms can affect the quality of life irrespective of the presence of oesophagitis. Proton pump inhibitors (PPIs) are far more effective than H2 receptor antagonists (H2RAs) or prokinetics with regard to the speed of symptom relief. Despite this undisputed progress, there is some conflict on whether symptoms should be managed until full resolution in endoscopy-negative patients or in those with mild oesophagitis. Considering that GORD is not a life-threatening condition, some authorities admit that patients should accept minimal residual symptoms. They argue that PPIs are expensive while healthcare resources are limited, and that long-term safety of PPIs has not been completely established. Moreover, they underline that many patients do not seek medical help and are satisfied with self-medication (with antacids/alginates or even over-the-counter H2RAs). On the other hand, some clinicians prefer a full resolution of symptom strategy because this is now achievable with modern PPIs without serious concerns in terms of tolerance and safety. Indeed, quality of life is rapidly restored by PPIs. Moreover, symptom relief by PPIs is highly predictive of healing, making endoscopic control unnecessary at least for mild/moderate oesophagitis. Finally, there is also some controversy over whether we should start treatment with PPIs or use less potent drugs as first-line therapy. If one considers not only the direct cost of drugs, but also the indirect ones (e.g. sick leave days), it is reasonable to think that PPIs may be more cost-effective than H2RAs or prokinetics, at least when the disease is of moderate or severe intensity. In conclusion, with modern PPIs like lansoprazole, rapid and full resolution of symptoms is now achievable in the large majority of patients.