Future GERD therapies seek faster relief
■ Currently, the most effective drugs for gastroesophageal reflux disease take time to produce an effect and have to be taken long term.
By Victoria Stagg Elliott — Posted June 13, 2005
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Future gastroesophageal reflux disease therapies will attempt to provide immediate relief while addressing the condition's underlying mechanisms, according to a panel discussion at Digestive Disease Week, held last month in Chicago.
"We need new molecules to provide truly on-demand therapy," said Nimish Vakil, MD, one of the panelists and a clinical professor of medicine at the University of Wisconsin Medical School in Madison.
DDW is an annual joint meeting of the American Assn. for the Study of Liver Diseases, the American Gastroenterological Assn., the American Society of Gastrointestinal Endoscopy, and the Society for Surgery of the Alimentary Tract.
Experts predicted that these strategies could involve combining currently available proton pump inhibitors, which work over the long term but take a while to kick in, with older acid-suppression drugs that work immediately but don't last as long. Entirely new compounds that approach the problem from a different angle are also a possibility. Research presented at DDW suggested that acid pump antagonists and potassium-competitive acid blockers both have significant potential to further relieve patients' symptoms.
"In the next few years, we should have some very interesting agents to help our patients with acid-related disorders," said Dr. Vakil.
Compliance an issue
A new approach is necessary because, although evidence suggests that addressing the underlying mechanisms can result in a higher quality of life, many people fail to adhere to this therapy because they do not receive the immediate pay-off, according to the panelists.
One study presented at the meeting found that patients who took PPIs experienced fewer symptoms than those who took antacids. Symptoms were not completely eliminated in either group, and the authors suggested that this may be because patients were not taking medications as instructed.
"This is a reminder to physicians that patients ... often still have troublesome symptoms of GERD," Dr. Roger Jones, lead author and professor of general practice at Guy's, King's and St. Thomas' School of Medicine in London. The authors suggested, however, that although patients may be experiencing symptoms they may not necessarily be suffering because of them. "People respond to symptoms differently," said Dr. Jones. "We're not trying to create a symptom-free world here."
In addition to looking for ways to make GERD therapy more effective, researchers are also looking for ways to better target and prescribe medicines at more appropriate doses. Two papers from researchers at the University of Alabama School of Medicine at Birmingham found that PPI therapy can improve asthma symptoms, especially in patients who also have GERD symptoms. GERD and asthma have long been linked.
"If people don't have esophageal symptoms, a PPI will not have a significant impact [on the asthma], but it will for subjects who have GERD as a trigger," said Susan Harding, MD, lead author on both papers and associate professor of pulmonology.
Some evidence also indicates that patients may be prescribed less medication while still getting similar symptom relief.
A Northwestern University Medical School study looked at the impact of a formulary change at a VA medical center from twice to once daily PPI treatment. Two-thirds of patients were well-managed on less medication with one-third having to go back to the higher dose. Authors said this may be an effective strategy to both control costs and increase adherence.
"We've been aggressively managing symptoms with PPIs. This study says we can back off without an increase in costs," said Gregory A. Cote, MD, lead author and a gastroenterology fellow. "We also know that adherence drops after four or five meds. Taking two PPIs could potentially come at the expense of taking other medications."