From the Journals

GERD symptoms affect one in three Americans

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Not all heartburn is GERD

Heartburn is a common symptom and is ubiquitously attributed to gastroesophageal reflux disease (GERD) among patients and clinicians. However, it is important to note that although most patients with GERD do have heartburn and/or regurgitation, many patients with these symptoms do not have GERD.

Dr. Dhyanesh A. Patel of Vanderbilt University, Nashville

Dr. Dhyanesh A. Patel

This population-based study by Delshad et al. highlights the prevalence of GERD symptoms and persistent GERD symptoms despite therapy based on a National Gastrointestinal Survey in 2015. They found that two of five participants reported GERD symptoms in the past, while one of three had symptoms in the last week. Although this highlights the high prevalence of reflux symptoms, it does not necessarily equate to a higher prevalence of GERD. This is highlighted by the fact that only 35% of patients with GERD symptoms were on therapy, suggesting that most of the patients did not find the symptoms frequent or troublesome enough to start therapy.

When the authors used a more precise definition of GERD based on the modified Montreal classification, they found that only 18% of the study population met the criteria for the disease. This is similar to prevalence of GERD reported in North America by other studies. The authors also found that, among patients on daily proton pump inhibitors (PPIs), 54% still reported persistent reflux symptoms.

Although this highlights the need for future research into developing other therapeutic modalities for GERD (such as bile acid sequestrants), most of the patients that are “PPI refractory” have lack of response because of a functional esophageal disorder. This is highlighted by the similar risk factors for functional heartburn and the PPI-refractory group in this study: younger individuals, women, and participants with irritable bowel syndrome.

Dhyanesh A. Patel, MD, is an assistant professor of medicine at the Center for Esophageal Disorders, Vanderbilt University Medical Center, Nashville, Tenn. He reported that he has no conflicts of interest.



For most patients, proton pump inhibitors do not control symptoms of gastroesophageal reflux disease, according to the findings of a large population-based survey study.

In all, 31% of respondents reported gastroesophageal reflux disease (GERD) symptoms within the past week, and 54% of those on proton pump inhibitors (PPIs) had breakthrough symptoms, said Sean D. Delshad, MD, MBA. In all, 54% of patients on PPIs for GERD reported having breakthrough symptoms of heartburn or regurgitation. Novel treatments are needed for patients with PPI-refractory symptoms of GERD, he and his associates wrote in Gastroenterology.

Prior population-based U.S. studies have reported a lower prevalence (16%-28%) of weekly or monthly GERD symptoms, noted Dr. Delshad of the Cedars-Sinai Center for Outcomes Research and Education in Los Angeles. However, the study cohorts do not reflect current U.S. demographics — two were 82%-90% white and the third was 43% African American. The most recent data also were collected approximately 15 years ago, the researchers noted.

For the study, they deployed a mobile app that guides users through an automated, online assessment of GI symptoms called AEGIS. Respondents were asked to select any GERD symptoms they had ever experienced and any symptoms they had experienced in the past week. Options included heartburn, acid reflux, gastroesophageal reflux, abdominal pain, bloating or gas, constipation, diarrhea, disrupted swallowing, fecal incontinence, nausea and vomiting, and “no symptoms.” All 71,812 respondents were recruited by a research firm and surveyed during a 3-week period in 2015.

In all, 44% of respondents reported having ever had heartburn, acid reflux, or gastroesophageal reflux, and 31% reported having GERD symptoms in the past week. In all, 55% of respondents who had ever experienced GERD symptoms were on PPIs, 24% were on histamine2 receptor blockers, and 24% were on antacid agents.

Among more than 3,000 participants on daily PPIs, 54% had persistent symptoms of GERD, which compares with the results of prior community-based studies, the investigators wrote. Current GERD symptoms and PPI-refractory GERD were especially prevalent among women, non-Hispanic whites, and individuals with comorbidities such as irritable bowel syndrome, diabetes, Crohn’s disease, and endometriosis.

In an adjusted analysis, Latinos were 2.44 times more likely to have PPI-refractory GERD ,compared with non-Hispanic whites. “The reason behind this finding is unclear but may be secondary to physiologic or even cultural etiologies,” the researchers wrote.

The more independent and functional middle-aged and older adults are more likely to respond to online surveys. Furthermore, although incentives were used to reduce participation bias, calling the tool a “GI Survey” could have made those with GI symptoms more likely to respond. The survey also did not assess if respondents were taking PPIs correctly or if they had made behavioral changes to mitigate GERD.

This study was sponsored by Ironwood Pharmaceuticals, whose bile acid sequestrant IW-3718 is in late-phase development as an add-on to PPI therapy for patients with persistent GERD. Dr. Delshad reported having no relevant conflicts of interest, but two coinvestigators disclosed consulting relationships with Ironwood Pharmaceuticals.

SOURCE: Delshad SD et al. Gastroenterology. 2019 Dec 10. doi: 10.1053/j.gastro.2019.12.014.

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