Approach to GERD

I read the article “Deprescribing proton pump inhibitors”¹ in the May issue of Canadian Family Physician with great interest. As a practising endoscopist I advocate for avoiding ongoing re-prescribing of proton pump inhibitors (PPIs) for patients with gastroesophageal reflux disease (GERD).

Farrell and colleagues¹ have successfully demonstrated evidence against the ongoing use of PPIs in GERD; however, they have not provided sufficient tools for primary care practitioners to assist patients with managing symptoms while not taking PPIs. In my practice I often see that when patients are not given effective education about GERD and elimination diets they become victims of different health marketing trends, which results in frustration due to failing at various diets. This leads them to return to the practitioner to request a PPI. Although there are many studies on dietary intervention in GERD, there is still no standard approach to a GERD diet. When studies such as those by Kaltenbach et al,² which was mentioned in the article,¹ and others^3,4 compare the effects of a GERD diet on GERD symptoms, they often compare similar but not the same approaches, and thus are not able to draw a clear conclusion on the effectiveness of a GERD diet. This leads to a lack of practical tools for practitioners to implement in patient care.

Farrell and colleagues also suggest that when a PPI and diet approach fail, a practitioner should ensure to test for and treat Helicobacter pylori.¹ I would disagree with this recommendation, as evidence of H pylori contributing to GERD is equivocal and even a reverse relationship has been demonstrated in several studies.^5–7 Moreover, the referenced study by Raghunath et al⁸ has clearly indicated that the opposite is true, as the study found that the eradication group had an increased prominence of heartburn.