2 Research recommendations
- 2.1 Patient characteristics, risk factors and predictors that indicate endoscopy for excluding Barrett's oesophagus
- 2.2 Laparoscopic fundoplication compared with medical management
- 2.3 Effective proton pump inhibitor dosage for severe erosive reflux disease
- 2.4 Other specialist management
- 2.5 Specialist investigation
The Guideline Development Group has made the following recommendations for research, based on its review of evidence, to improve NICE guidance and patient care in the future.
2.1 Patient characteristics, risk factors and predictors that indicate endoscopy for excluding Barrett's oesophagus
In people who experience symptoms of gastro-oesophageal reflux disease (GORD) or symptoms suggestive of GORD, what patient characteristics, risk factors and predictors indicate when endoscopy is needed to exclude Barrett's oesophagus?
What is the effectiveness of laparoscopic fundoplication compared with medical management in people with GORD that does not respond to optimal proton pump inhibitor (PPI) treatment?
Current evidence on the clinical and cost effectiveness of laparoscopic fundoplication compared with medical management involves people who had relatively good treatment control with PPIs at baseline. The driver was the desire to be free from medication rather than their GORD being non-responsive to PPIs.
What is the clinical effectiveness of double-dose PPIs in people with severe erosive reflux disease (Los Angeles classification grade C/D or Savary–Miller grade 3/4):
to reduce severe oesophagitis
to control symptoms
as maintenance therapy?
People with severe erosive reflux disease or severe oesophagitis (Los Angeles classification grade C/D or Savary–Miller grade 3/4) experience severe heartburn, and prolonged acid and pepsin exposure in the lower oesophagus, which can affect their day-to-day wellbeing. It would substantially improve people's quality of life if an optimal treatment regimen could be identified. Currently, there is a lack of evidence on the efficacy of 'double-dose' PPIs in treating severe erosive reflux disease.
What specialist management is effective for people whose symptoms do not respond to PPIs despite optimum primary care, or for people whose symptoms return after surgery?
There is a small group of people whose symptoms do not resolve, despite medical management and/or surgery for reflux. The group should be divided into people with proven (by pH monitoring) GORD and people with symptoms but no diagnosed reflux. The first group should have a trial of a twice-daily, high-dose PPI versus a standard or full-dose PPI. The second group should have a trial of tricyclic antidepressants versus standard or full-dose PPI. The purpose of any treatment should focus on improving quality of life.
What specialist investigations should be conducted to exclude a diagnosis of functional dyspepsia in people with uninvestigated dyspepsia that does not respond to PPIs or H2 receptor antagonists (H2RAs) despite optimum primary care?
People with uninvestigated dyspepsia that fails to respond to PPIs or H2RAs, despite optimum primary care, can have a poor quality of life. It is important to ensure that appropriate investigations are carried out to make the correct diagnosis or to correct misdiagnosis, so that the most appropriate treatment can be offered.