Feature Story

AHRQ releases the first Comparative Effectiveness Review: Certain drugs are as effective as surgery for management of GERD

Drugs can be as effective as surgery for management of gastroesophageal reflux disease (GERD), according to a report released by the Agency for Healthcare Research and Quality. The report is the first Comparative Effectiveness Review to be released by AHRQ's new Effective Health Care Program.

GERD, one of the most common health conditions among older Americans, results in $10 billion annually in direct health care costs. It occurs when stomach acid enters the esophagus, causing heartburn and potential damage to the esophagus. The study compares treatment approaches for chronic uncomplicated GERD, where the condition is likely to require life-long management but does not involve more serious disease of the esophagus.

The report indicates that for the majority of patients with uncomplicated GERD a class of drugs called proton pump inhibitors (PPIs) can be as effective as surgery in relieving the symptoms and improving quality of life. Although surgery is sometimes chosen with the goal of removing the need to take medications, the evidence is unclear as to whether a significant number of surgical patients are eventually able to stop using medications. The studies reviewed for this report show that 10 to 65 percent of patients resumed the use of medications.

The report also reviews treatment alternatives for chronic GERD including over-the-counter medications; PPI drugs; fundoplication surgery (wrapping the top part of the stomach around the bottom of the esophagus); and endoscopic procedures. The findings in the report apply to patients who have undergone diagnostic testing, and thus there is a high degree of certainty that symptoms are due to GERD.

For chronic GERD, over-the-counter H2 receptor antagonist medications are not as effective as PPIs, although PPIs have more side effects (headache, diarrhea, and abdominal pain). Examples of H2 receptor antagonists include Axid®, Pepcid®, Tagamet®, and Zantac®.

PPIs appear to have similar clinical effectiveness when compared with one another for treating GERD. Some statistically significant differences have been reported, but these differences are modest and the clinical implications are unclear. Examples of PPIs include AcipHex®, Nexium®, Prevacid®, Prilosec OTC, and Protonix®. Generic omeprazole is also available.

PPIs and fundoplication surgery appear to be similarly effective in relieving symptoms and improving quality of life.

The limited evidence suggests that medications and surgery have similar long-term effects for preventing the development of Barrett's esophagus or esophageal adenocarcinoma. Clinical experience with newer endoscopic procedures is increasing, but too little research has been done so far to make meaningful comparisons between PPIs and surgery.

The GERD report was prepared by the Tufts-New England Medical Center Evidence-based Practice Center, one of 13 such centers working under contract with AHRQ to generate syntheses of evidence regarding health care issues. Along with the report, AHRQ also released plain-language summaries to help consumers and others review the findings quickly and understand them. In creating the program, Congress emphasized the need for conveying the information at different levels of detail for different audiences, with special attention to making the findings useful for consumers.

The report is available at http://www.effectivehealthcare.ahrq.gov. This Web site includes features for the public to participate in the Effective Health Care Program. Users can sign up to receive notification when new reports are available. They can also be notified when draft reports and other features are posted for comment, and comments can be submitted through the Web site. The public is also invited to use the Web site to nominate topics for review by the Effective Health Care Program.

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