Experts Lay Down the Law on Acid Reflux
Panel Separates Treatment Facts from Fiction
By¬{omitted}Daniel¬{omitted}DeNoon
WebMD Medical News

Nov. 15, 2002 -- The acid reflux of heartburn comes with a common heartache -- doctors don't agree. They don't agree about treatment. They don't agree about testing. They don't agree about cancer risk. But now there's help.

A panel of experts convened by the American Gastroenterological Association has laid down the law on acid reflux in a 25-page document. It's sure to be controversial, as it contradicts beliefs held by many doctors. Walter L. Peterson, professor of internal medicine at the University of Texas Southwestern Medical Center, chaired the panel. He says he and his colleagues ignored hearsay and looked only at rigorous scientific evidence.

"This group of experts ... produced a document that may be controversial but is definitely factual," Peterson says in a news release.

Heartburn is caused by acid reflux, or GERD -- gastroesophageal reflux disease. Acid reflux happens when the muscle between the stomach and the esophagus gets weak or relaxes at the wrong time. This lets the contents of the stomach, including acid, splash up into the esophagus. The esophagus doesn't have the same kind of protective coating as the stomach, so stomach acids burn it.

Doctors treat acid reflux with over-the-counter drugs, prescription drugs, and surgery. What works? The panel of experts covered seven major questions.

What Over-the-Counter Treatment is Best?

Patients with mild or moderate acid reflux get relief from several different non-prescription drugs. There are several types:
Antacids neutralize stomach acids. These include drugs such as Tums and Rolaids.
H2 receptor antagonists reduce production of stomach acids. These include drugs such as Axid AR, Pepcid AC, Tagamet HB, and Zantac 75.
One drug -- Pepcid Complete -- combines an antacid with an H2 receptor antagonist.
The panel finds that all these drugs work to various degrees. It found that Pepcid Complete worked better than either an antacid or H2 receptor antagonist alone.

"For many patients with no 'red flags' -- experiencing heartburn for periods not exceeding four weeks -- over-the-counter agents provide rapid, effective, and safe relief," says panel member Hashem El-Serag, MD, MPH, in a news release.

What Prescription Treatment is Best?

Drugs known as proton-pump inhibitors are commonly prescribed to treat acid reflux. Proton pump inhibitors block release of stomach acids. These drugs include Aciphex, Nexium, Prevacid, Prilosec (now available in generic form), and Protonix.

The panel found few differences between these drugs. However, they note that Nexium may heal sores in the esophagus faster.

The panel recommends that patients and doctors choose the proton-pump inhibitor that costs the least.

Does Acid Reflux Lead to Cancer?

Chronic acid reflux can lead to a condition known as Barrett's esophagus or BE. BE has been thought to pose a significant risk of cancer. However, the panel found that this risk is no more than half as great as once thought. For most people, BE will not cause cancer.

It's a significant finding. Doctors routinely send BE patients for yearly screening with an endoscope, an instrument that is inserted down the throat. The panel now says that BE patients need such a test only once every three to five years.

What About New Endoscopic Treatments?

The FDA has approved two non-surgical treatments for acid reflux: the Stretta procedure and endoscopic suturing. The FDA approved these procedures based on their safety but was unsure of their effectiveness. Many doctors are using these techniques.

There are also two other techniques now in clinical trials: Enteryx and PMMA microspheres.

The panel concludes that all of these procedures are still experimental. It does not recommend their use, and it advises doctors to warn patients about the "risks associated with unproven therapies."

Can Surgery Cut the Need for Drugs or Prevent Cancer?

A common surgery for acid reflux is called fundoplication. It wraps the top of the stomach around the esophagus to keep stomach contents from backing up.

The panel notes that only four out of 10 patients are free of heartburn and no longer need drugs after this surgery.

"Patients should be informed to not expect they will no longer need medication or experience GERD symptoms," the panelists write. "Prevention of cancer is not an acceptable [reason] for surgery."

Should Heartburn Patients Undergo Endoscopy?

Doctors often refer heartburn patients to a specialist for endoscopy testing. However, the panel states that if patients' heartburn gets better after drug therapy they do not need such tests.

Does Acid Reflux Cause Asthma or Other Lung Symptoms?

Acid reflux patients often have asthma or other lung problems. However, the panel finds there is not enough evidence to say whether acid reflux causes these conditions.