Empiric PPI therapy or endoscopy for the initial management of patients with GERD in the absence of alarm features? Commentary

Most clinicians prescribe an empiric PPI trial for patients presenting with typical GERD symptoms in the absence of alarm features, but there are limited data available from randomized trials to support this approach. In this Practice Point commentary I discuss the findings and limitations of a randomized study conducted by Giannini and colleagues that evaluated the use of empiric therapy with esomeprazole versus endoscopy-oriented therapy for the initial management of patients with typical symptoms of GERD without alarm features. The results suggest that an empiric PPI trial has similar efficacy to, and is more cost-effective than, endoscopy-oriented therapy. However, I caution that the application of these results might not extend to patients with atypical presentations of GERD, and highlight the possibility that other diagnostic tools such as reflux monitoring or new endoscopic modalities might yield superior results to both empiric and endoscopy-oriented therapies in this setting.