Management strategies for gastro-oesophageal reflux disease

New trials allow management strategies to be proposed with greater confidence than in the past for the entire spectrum of gastro-oesophageal reflux disease. Symptom evaluation is of key importance, as it is the most cost-effective and sensitive method for diagnosis of gastro-oesophageal reflux disease, and for tailoring of long-term therapy to individual patients. Endoscopy is an important adjunct to symptom assessment, but needs to be used sparingly and critically to be cost-effective. Empirical therapy, with evaluation of symptom response, is a central management strategy that can minimize overall costs. In cases of diagnostic uncertainty, a 1–2-week diagnostic/therapeutic test with high dose acid pump inhibitor is an emerging attractive alternative to oesophageal pH monitoring. Choice of therapy, and its subsequent adjustment to individual patients, should be made in the light of a now well-defined hierarchy of efficacy, which is essentially the same for endoscopy-negative and oesophagitis patients. Management strategies must acknowledge that gastro-oesophageal reflux disease is a chronic disorder in the majority of oesophagitis and endoscopy-negative patients. Management steps should identify the most cost-effective long-term treatment that gives adequate relief of symptoms and so corrects any symptom-related impairment of quality of life. The strategies that are recommended are largely based on clinical trial outcomes. There is a need for formal clinical trials of management strategies as distinct from evaluations of specific therapies.