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. 2024 Aug;22(8):1709-1718.e3.
doi: 10.1016/j.cgh.2024.03.004. Epub 2024 Mar 20.

Behavioral Therapy for Functional Heartburn: Recommendation Statements

Livia Guadagnoli  1 , Rena Yadlapati  2 , John Pandolfino  3 , Alyse Bedell  4 , Anjali U Pandit  5 , Kerry B Dunbar  6 , Ronnie Fass  7 , Richard Gevirtz  8 , C Prakash Gyawali  9 , Stephen E Lupe  10 , Megan Petrik  11 , Megan E Riehl  12 , Jessica Salwen-Deremer  13 , Madison Simons  10 , Kathryn N Tomasino  5 , Tiffany Taft  5
Affiliations

Behavioral Therapy for Functional Heartburn: Recommendation Statements

Livia Guadagnoli et al. Clin Gastroenterol Hepatol. 2024 Aug.

Abstract

Background & aims: Brain-gut behavior therapies (BGBT) are increasingly recognized as effective therapeutic interventions for functional heartburn. However, recommendations regarding candidacy for treatment, initial treatment selection, and navigating treatment non-response have not been established for functional heartburn specifically. The aim of this study was to establish expert-based recommendations for behavioral treatment in patients with functional heartburn.

Methods: The validated RAND/University of California, Los Angeles Appropriateness Method was applied to develop recommendations. A 15-member panel composed of 10 gastrointestinal psychologists and 5 esophageal specialists ranked the appropriateness of a series of statements on a 9-point interval scale over 2 ranking periods. Statements were within the following domains: pre-therapy evaluation, candidacy criteria for BGBT, selection of initial BGBT, role of additional therapy for initial non-response to BGBT, and role of pharmacologic neuromodulation. The primary outcome was appropriateness of each intervention based on the recommendation statements.

Results: Recommendations for psychosocial assessment (eg, hypervigilance, symptom-specific anxiety, health-related quality of life), candidacy criteria (eg, motivated for BGBT, acknowledges the role of stress in symptoms), and treatment were established. Gut-directed hypnotherapy or cognitive behavioral therapy were considered appropriate BGBT for functional heartburn. Neuromodulation and/or additional BGBT were considered appropriate in the context of non-response.

Conclusions: Gut-directed hypnotherapy and/or cognitive behavioral therapy are recommended as appropriate behavioral interventions for heartburn symptoms, depending on clinical indication, specific gut-brain targets, and preferred treatment modality (pharmacologic vs non-pharmacologic). Pre-therapy evaluation of psychosocial processes and candidacy for BGBT are important to determine eligibility for referral to psychogastroenterology services.

Keywords: Behavioral Medicine; Esophageal Disorder; Health-Related Quality of Life; Heartburn; Psychogastroenterology.

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Conflict of interest statement

Disclosures: RY: Consultant for Medtronic, Phathom Pharmaceuticals, StatLinkMD, Reckitt Benckiser Healthcare Ltd; Research Support: Ironwood Pharmaceuticals; Advisory Board with Stock Options: RJS Mediagnostix; TT: Consultant for Abyle Health, Takeda, Healthline; SEL: consultant for Takeda and Ayble Health; MER: Consultant for GI OnDEMAND; RF: Advisor forTakeda, Medtronic, Phathom Pharmaceuticals, GERDCare, Celexio, Dexcal, Sanofi, Johnson & Johnson, Carnot, veritas, Syneos, BrainTree Labs/Sebela, Renexxion, speaker for Astrazeneca, Takeda, Laborie, Eisai Pharmaceuticals, Johnson & Johnson, Medicamenta, Adcock – Ingram, Carnot, Daewoong.

Figures

Figure 1.
Figure 1.. Illustration of the role of psychological processes in esophageal symptom experience
Figure 2.
Figure 2.. Overview of diaphragmatic breathing
Figure 3.
Figure 3.. Clinical algorithm for assessment and referral of functional heartburn patients to psychogastroenterology services
See this image and copyright information in PMC

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