Complications
Refractory Gastroesophageal Reflux Disease
Refractory
gastroesophageal reflux disease is the persistence of troublesome gastroesophageal
reflux disease symptoms in compliant patients despite standard treatment or twice-daily
dosing of proton pump inhibitor for at least 8 weeks. The troublesome symptoms
impair the patient's quality of life and may cause sleep disturbance and affect
work. Patients with non-erosive reflux disease commonly have proton pump inhibitor-resistant gastroesophageal
reflux disease symptoms. The causes include inadequate acid suppression, weakly
acidic/non-acidic reflux, reflux sensitivity or other non-reflux causes such as
functional heartburn, dysmotility, and eosinophilic esophagitis or overlap
syndrome with IBS and visceral hypersensitivity. Patients
are assessed also for non-adherence to lifestyle measures. The impaired proton
pump inhibitor treatment response may also be related to increased body weight and
P450 system genotypes which affect proton pump inhibitor metabolism. A specialist referral for further evaluation may
be considered in proton pump inhibitor therapy non-responders and may include
an upper GI endoscopy with or without enhanced imaging and function testing
(ambulatory pH monitoring and 24-hour combined impedance-pH studies/esophageal
manometry). Patients with suspected extraesophageal symptoms and who have
failed proton pump inhibitor therapy should be evaluated for non-gastroesophageal reflux
disease causes prior to starting GI evaluation with
endoscopy or function testing. Therapeutic options to consider include increasing the proton pump inhibitor dose, switching to a different proton pump inhibitor or potassium-competitive acid blocker, doubling the potassium-competitive acid blocker dose, changing medication time, or adding a prokinetic agent, an alginate or an H2RA at night.