Proton pump inhibitors in systemic sclerosis: a reappraisal to optimise treatment of gastro-oesophageal reflux disease

Abstract

Gastroesophageal reflux disease (GERD) is associated with significant morbidity in patients with systemic sclerosis (SSc). Although the introduction of proton pump inhibitors (PPIs) into clinical care have represented a major achievement in the management of oesophago-gastric problems in SSc, PPIs are seldom fully effective in SSc patients, and the utilization of maximum PPI dosages is a very frequent clinical practice. However, currently there is little evidence currently to support the empiric use of PPIs in SSc which is especially relevant in regard to safety concerns of long-term exposure with have been raised in the general population. The purpose of this viewpoint is to highlight the significant beneficial impact of PPIs on GERD in SSc, while considering the potential adverse effects in this patient population. Furthermore, we highlight the unmet needs of SSc patients with GERD, and also propose an agenda for future research to optimise the safe and effective use of PPIs in SSc.

Figure 1.

Management of symptomatic gastroesophageal reflux disease (GERD) in proton pump inhibitor (PPI) naive SSc patients and those established on PPI. Other causes odynophagia separate from GERD should also be potentially considered including presence of candida oesophagitis. In general, we do not advocate that gastroscopy should be performed in all SSc patients at baseline, but on the basis of a specific clinical indication (e.g., refractory GERD). Patients who initially respond to one type of PPI (e.g., omeprazole) may benefit from a trial of a different type of PPI (e.g., dexlansoprazole) e.g., due to better adherence from reduced frequency of dosing or differing drug treatment efficacy. Surgical intervention should be as a last resort in exceptional cases only and has a high probability of failure in the context of aperistalsis in SSc. H2RA: histamine-2 receptor antagonists; MDT: multi-disciplinary team; OGD: oesophago-gastro-duodenoscopy.

Figure 2.

Management of SSc patients with controlled gastroesophageal reflux disease (GERD) on proton pump inhibitor (PPI). H2RA: histamine-2 receptor antagonists.