A critical review of current medical therapy for gastroesophageal reflux disease.

Gastroesophageal reflux (GER) disease is a common, multifactorial medical condition that may be difficult to treat. Simple lifestyle modifications decrease reflux episodes and should serve as the cornerstone for medical therapy. Antacids or alginic acid may be helpful in mild disease but recent studies suggest they may be no better than placebo. Metoclopramide improves symptomatic GER disease but side effects are a major limiting factor. Only bethanechol and the histamine H2 antagonists have been conclusively shown to improve esophagitis significantly. Therefore, more severe disease is currently best treated with a histamine H2 antagonist alone or in combination with bethanechol. The treatment of GER complications and maintenance therapy have only been recently addressed in clinical trials, but again the histamine H2 antagonists may have a useful role. Five to 10% of patients may require antireflux surgery, but the competency of the repair appears to deteriorate with time. Future clinical trials need to address specific areas of difficulty including entry criteria, test of efficacy, study duration, and usefulness of combination drug therapy.