Treatment of PPI-resistant gastro-oesophageal reflux. A systematic review

Background and study aims Several studies have demonstrated the superiority of proton-pump inhibitors (PPIs) in resolving erosive gastro-oesophageal reflux disease (GORD). However, this first line of treatment can fail to control symptoms in around 30% of cases, especially in the presence of non-erosive GORD. In situations where the first line of treatment fails, there is a lack of concordance regarding the best strategy to apply. This study presents a systematic review of the trials which have tested second-line treatments after PPI failure. Methods The study was conducted according to the PRISMA statement. The systematic review included medical trials written in English which were published between 2000 and 2016 and were retrieved from PubMed and Scopus using the keywords ‘PPI-resistant gastro-oesophageal reflux’, ‘alginate AND gastro-oesophageal reflux’, ‘hyaluronic acid AND gastro-oesophageal reflux’, ‘prokinetics AND gastro-oesophageal reflux’, ‘sucralfate AND gastro-oesophageal reflux’ and ‘baclofen AND gastro-oesophageal reflux’. Results Ten randomised and non-randomised studies were included, which included 1515 patients of both sexes (mean age = 49.19 years, age range = 18–85, males = 700; 46.2%). Conclusions A personalised choice of the best treatment for PPI-resistant GORD should be based on the results of an upper endoscopy and pH/MII monitoring. For patients in situations where the first line of treatment fails, we encourage the execution of trials for testing double doses of PPIs against alternative medicaments.