The objectives of medical treatment of patients with
gastroesophageal reflux disease (
GERD) are relief of symptoms and healing of
esophagitis, which can be achieved, at least in part, by drugs which suppress
acid secretion. In patients with
GERD symptoms and/or mild
esophagitis, the best and most cost-effective therapeutic strategy is to start with a
proton pump inhibitor with subsequent trial of step down of the intensity of
therapy (e.g. H2-receptor antagonists). In patients with moderate or severe
esophagitis,
proton pump inhibitors are the mainstay of treatment and the most effective in preventing symptoms and
esophagitis. In patients with mild disease, the recurrence of symptoms is less frequent and many patients may not need continuous maintenance
therapy or may require treatment with either low dose
proton pump inhibitors, H2-receptor antagonists or
cisapride only. H. pylori eradication might be needed in
GERD patients on long-term treatment with
proton pump inhibitors, but the benefit of this strategy has not yet been adequately demonstrated. Antireflux surgery is a maintenance option for the young patient on long-term medical
therapy. Improved medical
therapy for
GERD might depend on future agents with different therapeutic targets, including
GABA inhibitors and
nitric oxide modulating drugs in the control of the lower sphincter esophagus and in motility disorders,
free radical scavengers in the prevention of mucosal damage and COX-2 specific inhibitors in the prevention of the progression of Barret's esophagus to
adenocarcinoma. Finally, the modulation of some
growth factors might have a potential role in delayed esophageal
ulcer healing, refractory
esophagitis and in
Barrett's esophagus.