Refractory gastroesophageal reflux disease (rGERD) can be characterized as symptomatic reflux or esophagitis despite an adequate trial of twice daily proton pump inhibitor (PPI) therapy. Patients with rGERD might describe their symptoms as heartburn, poorly localized chest pain, or acid reflux. Non-verbal patients (e.g. patients obtunded from the dying process) may be at risk of untreated GERD.

Processes that contribute to rGERD in palliative care patients include: increased esophageal acid exposure (i.e. secondary to gastric carcinoid tumors); opioid-induced gastroparesis/delayed emptying; and/or peristaltic deficiency associated with cirrhotic ascites; malignancy-induced bowel obstructions; and transient lower esophageal sphincter relaxation. rGERD should be considered in non-verbal patients who appear to be imminently dying and are uncomfortable, especially if they have a history of GERD, cancer, and/or cirrhosis.

Therapeutic management of rGERD should focus the underlying etiology (e.g. triple therapy for helicobacter pylori). However, in palliative care patients, prognosis, symptom distress, and clinical situation must be considered to determine the extent of diagnostic work-up (e.g. endoscopy, specialized consultation).

For many palliative care patients, empiric treatment of rGERD is followed.

Traditional acid suppressing agents
-Adding ranitidine at night for at least one month while on concurrent PPI therapy has been associated with improvements in general GERD symptom management in up to 74% of patients. Solutions containing sodium alginate decrease the severity and frequency of heartburn, especially when used postprandially. Likewise, sucralfate in two-to-four daily doses may improve rGERD as well as mucosal healing for erosive disease.

Targeted strategies to palliate rGERD
• Baclofen reduces regurgitation events and transient lower esophageal sphincter relaxation. Most commonly used doses are 10-30 mg/day, divided into twice-daily or three-times-daily doses.
• Metoclopramide may improve rGERD symptoms and nausea in patients with delayed esophageal peristalsis, delayed gastric emptying and partial bowel obstruction at oral or parenteral doses of 10 mg three to four times a day.
• Trazodone, citalopram and fluoxetine have been shown to reduce GERD symptoms in symptomatic patients with normal endoscopies.

Other considerations
• Tobacco use and alcohol consumption may reduce lower esophageal sphincter pressure, but cessation of these agents has not been clearly shown to lead to improvements in GERD symptoms.
• Head of bed elevation and avoidance of a late-night evening meal (within 2-3 hours of bedtime) could mitigate rGERD.
• Botulinum toxin injection can help patients with achalasia. Without confirmed lower esophageal sphincter non-relaxation, its use could worsen rGERD symptoms, however.
• Long-term PPI use, generally greater than eight weeks, without substantial clinical benefit is not generally recommended; it has been associated to increased risk of bone fracture, clostridium difficile infections, hypomagnesemia, and vitamin B12 deficiency.

See reference for more information.

Adapted from Greenfield A, Cook t, Pruskowski J. Management of refractory gastroesophageal reflux disease. Palliative Care Network of Wisconsin. Fast facts and concepts #377. Internet. Accessed on May 17, 2019.