Optimal acid suppressive treatment for adequate symptom relief and prevention of the complications of gastroesophageal reflux disease: differences in long-term clinical course and pathophysiology among disease subtypes

Gastroesophageal reflux disease (GERD) is a chronic long-standing disease. Most patients with GERD are thought to require long-term treatment with acid suppressants, with proton pump inhibitors being the drugs of choice in managing these patients. However, there has been no consensus about the frequency of spontaneous remission of GERD. Furthermore, the duration of treatment is individually based, and the end-point of treatment is also not clear. As the symptoms of GERD may be intermittent or occur on most days of the week, treatment may be short term, lasting 8–12 weeks, or long term, lasting more than 1 year. Moreover, treatment may be continuous, intermittent, or on-demand. In contrast, maintenance therapy consists of the lowest proton pump inhibitor dose necessary for adequate symptom relief and prevention of GERD-related complications. GERD has been classified into three subgroups based on endoscopic severity: non-erosive reflux disease (NERD), mild erosive esophagitis (EE), and severe EE. Because these three subgroups differ in long-term clinical course and pathophysiology, their treatment strategies should differ. Treatment of severe EE should include two clinical goals: relief of GERD symptoms and prevention of EE-related complications, such as esophageal ulcer bleeding and/or strictures. However, because mild EE, including NERD, rarely progresses to severe EE during symptom-driven treatment, treatment of these patients should have one clinical goal: relief of GERD symptoms.