Drugs for the treatment of gastro-oesophageal reflux: in search of clear evidence-based indications.

oesophageal reflux: in search of clear evidence-based indications Keady presents some updated guidelines on the drug treatment of gastro-oesophageal reflux (GOR) and gastro-oesophageal reflux disease (GORD). However, in order to provide clear management guidelines, we believe that the review should have first addressed the definition of GOR (ie, physiological) versus GORD (ie, pathological). In fact, the results of a recent survey on the knowledge, attitudes and practice styles of North American paediatricians regarding GOR show that many infants are still inappropriately treated for GORD when all they have is physiological GOR. The first important goal of future educational efforts should therefore be directed to avoid over-treatment of ‘‘happy spitters’’ (ie, GOR). Secondly, in his conclusions Keady correctly stresses that ‘‘the majority of drugs used have limited robust data supporting their use’’. However, some evidence from randomised controlled trials (RCTs) is now available, but it is not clearly reflected by the practice guidelines suggested by Keady. An example of this is the use of prokinetic drugs (domperidone or erythromycin), in association with an appropriate acid suppressant, recommended for the treatment of moderate to severe GORD. A recent systematic review of RCTs showed that, even from the limited evidence available (the four RCTs were also named by Keady), domperidone does not appear to be more effective than placebo in reducing symptoms of GOR and GORD. Given the usually benign nature of GOR, the widespread use of prokinetic drugs is therefore not indicated. In severe cases of GORD, where medical management is required, available evidence suggests that domperidone is not indicated either. Its use could be re-considered if further data were to provide robust evidence of a favourable riskbenefit profile. The overall variability in practice style and lack of conformity with NASPGHAN (North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition) GORD guidelines merit further efforts in education and in terms of guideline availability based on the results of good clinical trials with relevant outcome measures. Federico Marchetti, Jenny Bua, Alessandro Ventura Department of Paediatrics, Institute of Child Health, IRCCS Burlo Garofolo, Trieste, Italy