Management of patients with symptomatic gastroesophageal reflux disease: a primary care perspective

The availability of antacids and over the counter (OTC) histamine 2 (H2) receptor antagonists provide ample opportunity for individuals with symptomatic reflux to self-medicate before or instead of visiting a physician. Because many patients will not achieve complete relief from OTC products, clinicians will be required to rethink treatment strategies for those who present with persistent reflux symptoms after a trial of low dose H2 receptor antagonists or other antisecretories. Patients with persistent heartburn or regurgitation without evidence of "alarm symptoms" will usually not require a diagnostic study of the upper GI tract. Counseling on lifestyle modifications and empirical antisecretory therapy is indicated in most situations. Proton pump inhibitors have consistently demonstrated superior symptom relief when compared to H2 antagonists for patients with erosive esophagitis and for patients with nonerosive disease. If proton pump inhibitors consistently reduce the need for physician visits and diagnostic testing, they would seem to be a logical first choice pharmaceutical for individuals who fail to improve with OTC H2 antagonists.