Potential Risks with PPIs and Complications Associated with GERD

Potential risks associated with PPIs

1. Switching PPls can be considered in the setting of side effects. (Conditional recommendation, low level of evidence)
2. Patients with known osteoporosis can remain on PPl therapy. Concern for hip fractures and osteoporosis should not affect the decision to use PPI long-term except in
patients with other risk factors for hip fracture. (Conditional recommendation, moderate level of evidence)
3. PPI therapy can be a risk factor for Clostridium difficile infection and should be used with care in patients at risk. (Moderate recommendation, moderate level of
evidence)
4. Short-term PPl usage may increase the risk of community-acquired pneumonia. The risk does not appear elevated in long-term users. (Conditional recommendation,
moderate level of evidence)
5. PPI therapy does not need to be altered in concomitant clopidogrel users as there does not appear to be an increased risk for adverse cardiovascular events.
(Strong recommendation, high level of evidence)

Extraesophageal presentations of GERD: Asthma, chronic cough, and laryngitis

1. GERD can be considered a potential co-factor in patients with asthma, chronic cough, or laryngitis. Careful evaluation for non-GERD causes should be undertaken in
all of these patients. (Strong recommendation, moderate level of evidence).
2. A diagnosis of reflux laryngitis should not be made based solely upon laryngoscopy findings. (Strong recommendation, moderate level of evidence)
3. A PPI trial is recommended to treat extraesophageal symptoms in patients who also have typical symptoms of GERD. (Strong recommendation, low level of evidence)
4. Upper endoscopy is not recommended as a means to establish a diagnosis of GERD-related asthma, chronic cough, or laryngitis. (Strong recommendation, low level of
evidence)
5. Reflux monitoring should be considered before a PPI trial in patients with extraesophageal symptoms who do not have typical symptoms of GERD. (Conditional recommendation, low level of evidence)
6. Non-responders to a PPI trial should be considered for further diagnostic testing and are addressed in the refractory GERD section below. (Conditional recommendation,
low level of evidence)
7. Surgery should generally not be performed to treat extraesophageal symptoms of GERD in patients who do not respond to acid suppression with a PPL. (Strong
recommendation, moderate level of evidence)

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GERD refractory to treatment with PPIs

1. The first step in the management of refractory GERD is an optimization of PPl therapy. (Strong recommendation, low level of evidence)
2. Upper endoscopy should be performed in refractory patients with typical or dyspeptic symptoms principally to exclude non-GERD etiologies. (Conditional recommendation,
low level of evidence)
3. In patients in whom extraesophageal symptoms of GERD persist despite PPI optimization, assessment for other etiologies should be pursued through concomitant
evaluation by ENT, pulmonary, and allergy specialists. (Strong recommendation, low level of evidence)
4. Patients with refractory GERD and negative evaluation by endoscopy (typical symptoms) or evaluation by ENT, pulmonary, and allergy specialists (extraesophageal
symptoms), should undergo ambulatory reflux monitoring. (Strong recommendation, low level of evidence)
5. Reflux monitoring off medication can be performed by any available modality (pH or impedance-pH). (Conditional recommendation, moderate level evidence). Testing on
medication should be performed with impedance-pH monitoring in order to enable the measurement of nonacid reflux. (Strong recommendation, moderate level of evidence).
6. Refractory patients with objective evidence of ongoing reflux as the cause of symptoms should be considered for additional antireflux therapies, which may include
surgery or TLESR inhibitors. (Conditional recommendation, low level of evidence). Patients with negative testing are unlikely to have GERD and PPl therapy should be discontinued. (Strong recommendation, low level of evidence)

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Complications Associated with GERD

1. The Los Angeles (LA) classification system should be used when describing the endoscopic appearance of erosive esophagitis. (Strong recommendations, moderate level
of evidence). Patients with LA Grade A esophagitis should undergo further testing to confirm the presence of GERD. (Conditional recommendation, low level of evidence)
2. Repeat endoscopy should be performed in patients with severe erosive reflux disease after a course of antisecretory therapy to exclude underlying Barrett’s oesophagus.
(Conditional recommendation, low level of evidence)
3. Continuous PPI therapy is recommended following peptic stricture dilation to improve dysphagia and reduce the need for repeated dilations. (Strong recommendation,
moderate level of evidence)
4. Injection of intralesional corticosteroids can be used in refractory, complex strictures due to GERD. (Conditional recommendation, low level of evidence)
5. Treatment with a PPI is suggested following dilation in patients with lower oesophagal (Schatzki) rings. (Conditional recommendation, low level of evidence) 6. Screening for Barrett’s oesophagus should be considered in patients with GERD who are at high risk based on the epidemiologic profile. (Conditional recommendation, moderate level of evidence)
7. Symptoms in patients with Barrett’s oesophagus can be treated in a similar fashion to patients with GERD who do not have Barrett’s oesophagus. (Strong recommendation,
moderate level of evidence)
8. Patients with Barrett’s oesophagus found at endoscopy should undergo periodic surveillance according to guidelines. (Strong recommendation, moderate level of evidence) ENT, ear, nose, and throat; GERD, gastroesophageal reflux disease; LA, Los Angeles; PPI, proton pump inhibitor.

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