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Review article: rethinking the “ladder” approach to reflux-like symptom management in the era of PPI “resistance”: a multidisciplinary perspective

Hungin, A. Pali S.; Scarpignato, Carmelo; Keefer, Laurie; Corsetti, Maura; Anastasiou, Foteini; Muris, Jean W.M.; Mendive, Juan M.; Kahrilas, Peter J.


A. Pali S. Hungin

Carmelo Scarpignato

Laurie Keefer

Foteini Anastasiou

Jean W.M. Muris

Juan M. Mendive

Peter J. Kahrilas


Background: Despite widespread adoption of potent acid suppression treatment with proton pump inhibitors (PPI) for reflux-like symptoms, persistent symptoms are commonly reported in primary care and community studies. Aims: This multidisciplinary review critically evaluates how the management of reflux-like symptoms could better reflect their multifactorial pathophysiology. Methods: A panel of experts (from general practice, gastroenterology and gastropsychology) attended a series of workshops to review current management and propose a framework for the provision of more individualised care. Results: It was agreed that the perceptual (as well as the physiological) causes of reflux-like symptoms should be considered at the start of management, not as a last resort when all else has failed. A short course of PPI is a pragmatic approach to address reflux-like symptoms, but equally important is counselling about the gut-brain axis and provision of symptom-specific behavioural interventions for those who show signs of somatisation, hypervigilance or co-existing disorders of gut-brain interaction. Other low-harm interventions such as lifestyle and dietary advice, should also be better integrated into care at an early stage. Multidisciplinary care management programmes (including dietary, weight loss, exercise and behavioural intervention) should be developed to promote greater self-management and take advantage of the general shift toward the use of remotely accessed health care resources. Conclusions: Management of reflux-like symptoms should be adapted to reflect the advances in knowledge about the multifactorial aetiology of these symptoms, addressing both acid-related and behavioural components early in management. The time has come to treat the patient, not the “disease”.


Hungin, A. P. S., Scarpignato, C., Keefer, L., Corsetti, M., Anastasiou, F., Muris, J. W., …Kahrilas, P. J. (2022). Review article: rethinking the “ladder” approach to reflux-like symptom management in the era of PPI “resistance”: a multidisciplinary perspective. Alimentary Pharmacology and Therapeutics, 55(12), 1492-1500.

Journal Article Type Review
Acceptance Date Apr 5, 2022
Online Publication Date Apr 22, 2022
Publication Date 2022-06
Deposit Date Apr 6, 2022
Publicly Available Date Apr 23, 2023
Journal Alimentary Pharmacology and Therapeutics
Print ISSN 0269-2813
Electronic ISSN 1365-2036
Publisher Wiley
Peer Reviewed Peer Reviewed
Volume 55
Issue 12
Pages 1492-1500
Public URL
Publisher URL


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