What is appropriate medical systemic therapy for symptoms associated with BO?
Medical systemic therapy for patients with Barrett’s Oesophagus aims to control symptoms and reduce the risk of complications, including those related to peptic damage and (potentially) progression to adenocarcinoma. Uncomplicated Barrett’s Oesophagus itself is not a cause of symptoms, indeed patients with Barrett’s Oesophagus may have reduced sensitivity to oesophageal acidification, rather these are due to the effects of gastrooesophageal reflux on the squamous mucosa above the Barrett’s Oesophagus and to regurgitation of refluxate. As a group, patients with Barrett’s Oesophagus have greater acid exposure than patients with less endoscopically severe reflux disease. The general principles of medical systemic therapy for symptoms are essentially identical to treatment of the more severe forms of reflux oesophagitis without evidence of Barrett’s Oesophagus. The quality of evidence in the assessment of the control of symptoms specifically in patients with Barrett’s Oesophagus is poor, with few comparative randomised trials. Most information is derived from observational studies and medical treatment arms of comparative studies with surgical therapy or studies into other aspects of therapy (eg regression of metaplasia or control of intraoesophageal pH).
Asymptomatic Barrett’s Oesophagus
A subpopulation of patients with Barrett’s Oesophagus have minimal or no typical reflux symptoms, but may still be at risk of complications. The value of medical systemic treatment in currently asymptomatic patients with Barrett’s Oesophagus and no macroscopic evidence of peptic oesophagitis diagnosed incidentally has not been examined. Patients with evidence of peptic oesophagitis should be treated to prevent the development of stricture.
H2 Receptor Antagonist therapy
In the pre Proton Pump Inhibitor Therapy (PPI) era the use of cimetidine and ranitidine (+ antacid/other antisecretory agents) was shown to be effective in treating symptoms due to reflux in patients with Barrett’s Oesophagus. These studies were small and selection of patients was not described. Up to 43% of patients may require higher doses than standard therapy to control symptoms, but on an escalating dose regimen most patients’ symptoms can be controlled.
Proton Pump Inhibitor Therapy
Largely observational studies (sometimes the medical arm of a randomised study) show that most patients can be adequately controlled from a symptomatic point of view on PPI therapy, although in a significant proportion treatment with higher doses of PPI is required. Control of symptoms does not, however, equate to control of oesophageal acidification.
Comparison of PPIs has not shown any PPI to be consistently superior to another in the control of symptoms in patients with Barrett’s Oesophagus.
In patients with symptoms controlled on Ranitidine, changing to omeprazole did not result in better control. Comparison of PPI to H2RA in a single trial showed that PPIs were superior in controlling symptoms.
No studies have been performed to demonstrate that either prokinetic therapy alone, or its addition to acid suppression therapy has therapeutic value in the treatment of symptoms in patients with Barrett’s Oesophagus.
Evidence summary and recommendations
|Acid suppression with PPI is the most effective systemic therapy for reflux symptoms in patients with Barrett’s Oesophagus and can be expected to control symptoms in most patients with a durable effect over years||II, IV||, , , , , , , , , , |
|Higher than standard doses of PPI may be required to control symptoms in a proportion of patients.||IV||, , |
|Symptomatic patients with Barrett’s Oesophagus should be treated with Proton Pump Inhibitor therapy (PPI), with the dose titrated to control symptoms.||C|
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