From the Guidelines
Aggressive acid suppression therapy with proton pump inhibitors (PPIs) and lifestyle modifications is crucial in managing gastroesophageal reflux disease (GERD) in patients with scleroderma to reduce the risk of developing Barrett's esophagus. The use of prokinetic drugs, such as domperidone, should be considered for the treatment of symptomatic motility disturbances related to scleroderma, as reported in the 2023 update of the EULAR recommendations for the treatment of systemic sclerosis 1.
Key Management Strategies
- PPIs, such as omeprazole (20-40 mg twice daily), esomeprazole (20-40 mg daily), or pantoprazole (40 mg daily), should be taken 30-60 minutes before meals for optimal effect
- Lifestyle modifications, including elevating the head of the bed 6-8 inches, avoiding meals 2-3 hours before bedtime, eliminating trigger foods (caffeine, alcohol, chocolate, fatty foods), and maintaining a healthy weight
- Prokinetic agents, such as domperidone, may help improve esophageal clearance and gastric emptying, though their use may be limited by side effects, as seen in a study where domperidone and alginic acid had similar improvement in GERD symptoms 1
- Regular endoscopic surveillance is recommended every 2-3 years to monitor for Barrett's esophagus development
Rationale
The aggressive approach is necessary because scleroderma causes both esophageal dysmotility and lower esophageal sphincter dysfunction, creating a perfect environment for chronic acid exposure and increased risk of Barrett's esophagus and subsequent adenocarcinoma. The task force acknowledged the substantial unmet need for better control of GI manifestations in SSc, highlighting the importance of optimal management strategies 1.
From the Research
Gastroesophageal Reflux Disease (GERD) Management in Scleroderma Patients
To reduce the risk of developing Barrett's esophagus, managing GERD in patients with scleroderma is crucial. The following points highlight the relationship between scleroderma, GERD, and Barrett's esophagus:
- Scleroderma patients often experience esophageal symptoms such as heartburn and dysphagia due to smooth muscle dysfunction, leading to esophageal aperistalsis and reduced lower esophageal sphincter pressures 2.
- Aggressive medical therapy is necessary to prevent complications of gastroesophageal reflux, including peptic stricture and Barrett's esophagus 2.
- Goals of long-term GERD management include relief of symptoms, healing of esophagitis, prevention of its relapse, and prevention of complications with safe, cost-effective therapy 3.
- Proton pump inhibitors (PPIs) such as lansoprazole or omeprazole are recommended for maintaining GERD patients with severe reflux esophagitis or complications like peptic stricture or Barrett's esophagus 3.
Treatment Options for GERD in Scleroderma Patients
The following treatment options are available for managing GERD in scleroderma patients:
- Prokinetic drugs have a limited role except in symptomatic nonerosive GERD 3.
- H2-receptor antagonists are useful in relapsing, nonerosive GERD or in cases of mild initial esophagitis 3.
- PPIs are effective and safe agents for the treatment of GERD, and a strategy of PPIs first may be the most cost-effective approach 4.
- Antireflux surgery is a viable option for young and otherwise healthy patients 3.
Barrett's Esophagus in Scleroderma Patients
The following points highlight the relationship between Barrett's esophagus and scleroderma:
- Barrett's esophagus is a complication of GERD, and its development is unclear, but pulses of acid or bile may increase cell proliferation and cyclooxygenase-2 expression in Barrett's epithelium cell cultures 4.
- Short-segment Barrett's esophagus is associated with an increased risk of dysplasia or cancer compared to intestinal metaplasia of the cardia 4.
- Treatment with omeprazole 20 mg daily for up to 6 years did not cause regression in the length of the Barrett's segment but led to partial re-epithelialization in the form of squamous islands in over half of the patients 5.
- Screening for Barrett's esophagus in scleroderma patients is essential, as it can manifest as intestinal metaplasia, and its development is unrelated to age, disease duration, or lung pathology 6.