Long-term management of gastroesophageal reflux disease.

Gastroesophageal reflux disease is a common disorder for which a range of treatment options is now available. Most information relates to short-term treatment, but in many respects it is questions concerning long-term management that cause physicians and patients most difficulty. Review of older evidence and some more modern studies shows that reflux disease is not invariably a chronic, unremitting condition and that in a significant number of patients, acceptable long-term management requires only intermittent symptomatic therapy or no medication at all. For those patients requiring continuous maintenance medication, current evidence implies that proton pump inhibitors, prokinetic agents such as cisapride and surgical treatment are the main options to be considered. The selection of therapeutic strategies for long-term management of reflux disease should involve consideration of patient preferences and opinions. In many cases this reveals the acceptability of a p.r.n. approach to symptom control, where medication is given only when required. Clinical trials and proposed management algorithms which presume complete symptom abolition and complete resolution of esophagitis to be the desirable therapeutic goals need to justify these assumptions in the face of evidence which seems to suggest that patients may think differently.