title: Step-down management of gastroesophageal reflux disease.
abstract: OBJECTIVE
  As the economic burden of gastroesophageal reflux disease (GERD) is largely weighted to maintenance as opposed to initial therapy, switching from more potent to less expensive medication once symptoms are alleviated (step-down therapy) may prove to be most cost-effective. This study aimed to prospectively evaluate the feasibility of step-down therapy in a cohort of patients with symptoms of uncomplicated GERD.
  
  
  METHODS
  Patients whose GERD symptoms were alleviated by proton pump inhibitors (PPIs) were recruited from outpatient general medicine clinics. After baseline demographic and quality of life information were obtained, PPIs were withdrawn from subjects in a stepwise fashion. Primary outcome was recurrence of symptoms during follow-up that required reinstitution of PPIs. Secondary outcomes included changes in quality of life and overall cost of management. Predictors of nonresponse to step-down were assessed.
  
  
  RESULTS
  Seventy-one of 73 enrolled subjects completed the study. Forty-one of 71 (58%) were asymptomatic off PPI therapy after 1 year of follow-up. Twenty-four of 71 (34%) required histamine 2-receptor antagonists, 5/71 (7%) prokinetic agents, 1/71 (1%) both, and 11/71 (15%) remained asymptomatic without medication. Quality of life did not significantly change, whereas management costs decreased by 37%. Multivariable analysis revealed younger age and a dominant symptom of heartburn to predict PPI requirement.
  
  
  CONCLUSIONS
  Step-down therapy is successful in the majority of patients and can decrease costs without adversely affecting quality of life.
authors.affiliation: Veterans Administration Center for Practice Management and Outcomes Research, Ann Arbor, Michigan 48105, USA. jinadomi@umich.edu
authors.forename: J M
authors.initials: JM
authors.lastname: Inadomi
authors.forename: R
authors.initials: R
authors.lastname: Jamal
authors.forename: G H
authors.initials: GH
authors.lastname: Murata
authors.forename: R M
authors.initials: RM
authors.lastname: Hoffman
authors.forename: L A
authors.initials: LA
authors.lastname: Lavezo
authors.forename: J M
authors.initials: JM
authors.lastname: Vigil
authors.forename: K M
authors.initials: KM
authors.lastname: Swanson
authors.forename: A
authors.initials: A
authors.lastname: Sonnenberg
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005764:Gastroesophageal Reflux / Q000188:drug therapy* / Q000523:psychology; D017048:Health Care Costs; D006633:Histamine Antagonists / Q000627:therapeutic use; D006801:Humans; D008875:Middle Aged; D011446:Prospective Studies; D054328:Proton Pump Inhibitors; D011788:Quality of Life
chemical_list: D006633:Histamine Antagonists; D054328:Proton Pump Inhibitors