Management of Gastroesophageal Reflux Disease in primary Care: Results of a Survey in 2 Areas in Germany

Abstract

Background: The incidence of gastroesophageal reflux disease (GERD) is increasing. Although guidelines have been issued on the diagnosis and treatment of GERD, the way in which these should be applied in everyday practice is unclear. The aim of the present survey was to interview private-practice physicians on their personal opinions concerning the management of GERD.

Methods: A questionnaire based on the case of a typical patient with reflux was sent out to a total of 918 private-practice physicians. The questions concerned general measures for avoiding reflux symptoms (dietary and lifestyle modifications), the diagnosis of GERD, and the type and dosage of antireflux treatment.

Results: A total of 255 questionnaires were evaluated (28 %), which had been returned by 151 family doctors, 63 internal medicine specialists, and 41 gastroenterologists. 70 % of the respondents carry out specific diagnostic tests (endoscopy in 98 % of cases) prior to treatment. Altering specific dietary and lifestyle factors (such as sleeping position) was considered useful by the majority of respondents. 99 % of the physicians administer some form of GERD therapy, and 88 % of the internists/gastroenterologists and 74 % of family doctors (P  =  0.006) do so using a ”step-down” approach (with proton-pump inhibitors as the initial strategy). With the ”step-up” procedure, the initial recommendation includes primarily antacids, with a change to more effective drugs only when symptomatic relief is not achieved.

Conclusions: The current guidelines on the diagnosis and treatment of GERD are largely adhered to, particularly by specialists. In addition to the well-established drug treatment, empirical recommendations on dietary and lifestyle measures still form part of the management of GERD, despite the lack of scientific evidence to support them.

Zusammenfassung

Fragestellung: Die gastroösophageale Refluxkrankheit (GÖR) nimmt zu. Richtlinien zur Therapie und Diagnose der GÖR existieren, unklar ist jedoch, ob diese auch in der Praxis angewandt werden. Ziel der Arbeit war daher eine anonymisierte Befragung niedergelassener Ärzte zu ihrem persönlichen Management der GÖR.

Methodik: Ein Fragebogen basierend auf einem Fall eines typischen Refluxpatienten wurde an insgesamt 918 niedergelassene Ärzte verschickt. Gefragt wurden allgemeine Ratschläge zur Vermeidung von Refluxsymptomen (Modifikation von Diät und Lebensweise), Diagnostik der GÖR sowie Art und Dosierung einer medikamentösen Therapie.

Ergebnisse: 255 Fragebogen konnten ausgewertet werden (151 Allgemeinmediziner, 104 Internisten, darunter 41 Gastroenterologen). Etwa 70 % halten eine weitere diagnostische Abklärung vor der Therapie sinnvoll, in 98 % per Endoskopie. Spezifische Verhaltensregeln zu Diät, Alkohol, Schlafposition etc. werden mehrheitlich als sinnvoll erachtet. 99 % aller Befragten therapieren die GÖR, wobei 88 % der Fachärzte und 74 % der Allgemeinärzte (p = 0,006) eine „Step-down”-Strategie wählen (Protonenpumpeninhibitoren als initiale Therapie). Wurde die „Step-up”-Strategie gewählt, so werden zunächst hauptsächlich Antazida empfohlen; erst bei fehlendem Erfolg wird auf wirksamere Medikamente gewechselt.

Schlussfolgerung: Bestehende Richtlinien zur Diagnose und Therapie der GÖR werden weitgehend - vor allem von Fachärzten - übernommen. Neben der medikamentösen Therapie scheinen empirische Ratschläge zu Diät und Lebensweise immer noch trotz des fehlenden wissenschaftlichen Nachweises eine Rolle im Management der GÖR zu spielen.

Key words

Gastroesophageal Reflux - GERD - Therapy - Diagnosis - Questionnaire

Schlüsselwörter

Gastroösophagealer Reflux - GÖR - Therapie - Diagnose - Fragebogen

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Appendix: Questionnaire

Case: A 55-year-old insurance company employee (weight 87 kg, height 177 cm) reports frequent belching of acid and wind, mainly after eating, that has persisted for several years. He states that he has often experienced an unpleasant taste in his mouth when tying his shoelaces or bending over. He rarely suffers heartburn, but has recently been getting it more often than usual, sometimes so severely that his wife finally managed to persuade him to see the doctor. Otherwise the patient has no symptoms, and so far as he knows he has till now always been in good health.

The patient drinks about 0.5-1 liter of beer per day, and sometimes a glass of wine in the evening. During a working day he drinks 2-4 cups of coffee. Breakfast consists of 2 rolls or slices of toast with butter and marmalade, at lunchtime he selects the daily menu at the canteen, and in the evenings he eats 3-4 open sausage sandwiches or cheese sandwiches, and sometimes a little salad.

The patient likes going hiking, and plays tennis about twice a week in summer.

Until about 10 years ago the patient smoked about 30 cigarettes a day, now he only smokes about 10. He has no history of taking medication.

The patient’s father died of an apoplectic stroke at the age of 73, and his mother is still in generally good health at the age of 80.

Questionnaire

Please answer the following questions by marking the answers with a cross (multiple responses are possible). Please note that your advice should only apply to the patient’s reflux symptoms.

On the basis of the symptoms, I would advise the patient:

On diet:

• Avoid foods that are fatty ( ), sweet ( ), salty ( ), spicy ( ), sour ( ), bloating ( )

• No modification necessary, as there is probably no benefit ( )

• Other ( ):

On drinking habits:

• Restrict alcohol consumption/generally abstain ( ), … or only drink no beer ( ), no red wine ( ), no white wine ( ), nothing ”high-proof” ( )

• Avoid sour juice drinks ( ), cola ( ), coffee ( ), carbonated drinks ( )

• Only take caffeine-free drinks ( )

• No modification necessary, as there is probably no benefit ( )

• Other ( ):

On posture and sleeping position:

• Avoid activities requiring bending ( )

• Leave an adequate period (> 3 h) between eating and going to bed ( )

• Better to sleep with the head of the bed raised ( ), sleep on the right side ( ), sleep on the left side ( ), sleep on the back ( ), sleep on front

• No modification necessary, as there is probably no benefit ( )

• Other ( ):

On sport and exercise:

• Get as much exercise/sporting activity as possible ( )

• Take as little exercise/sporting activity as possible ( )

• Changing habits is of no benefit ( )

Do you recommend the patient to reduce weight?

Yes ( ) No, as there is probably no benefit ( )

Do you recommend the patient to stop smoking?

Yes ( ) No, as there is probably no benefit ( )

Do you think further diagnostic clarification is necessary before starting any treatment for the reflux symptoms?

No ( ) Yes, always ( ) Only if the symptoms persist ( )

If yes, what diagnostic steps would you take, in what sequence?

	Radiography	Endoscopy	pH-metry/manometry
1	( )	( )	( )
2	( )	( )	( )
3	( )	( )	( )

What is your approach to subsequent treatment?

• No drug treatment ( )

• Start drug treatment at once ( )

• Start drug treatment after getting results of awaited examinations ( )

If prescribing drugs for the patient, what do you initially do?

• ”Step up”: Initial treatment with what I consider more weakly effective drugs (please enter the name[s] of the drug[s] and dosage):

• ”Step down”: initial treatment with what I consider more strongly effective drugs (please enter the name[s] of the drug[s] and dosage):

What do you do if there is a good response to your treatment?

• Continue the existing treatment ( )

• Same drug, but at reduced dosage ( )

• Change to a different drug ( ) (Name, dosage?)

• No further treatment necessary ( )

What do you do if there is a poor response to your treatment?

• Continue the existing treatment ( )

• Same drug, but at higher dosage ( )

• Change to a different drug ( ) (Name, dosage?)

• Refer to a specialist/hospital ( )