Expert recommendations for the management of refractory gastroesophageal reflux disease in systemic sclerosis: A report from the World Scleroderma Foundation (WSF) Gastrointestinal "Ad hoc committee".

Abstract

Background: Gastro-esophageal reflux disease (GERD) occurs in most (~75%) patients with systemic sclerosis (SSc) and significantly impacts quality of life. Current recommendations lack depth and therefore, our aim was to produce practical, consensus-based recommendations for refractory SSc-related GERD.

Methods: An international, multidisciplinary Steering Board (SB) was assembled (n=19) consisting of clinicians (rheumatologists, gastroenterologists, GI surgeons), an expert methodologist, and patient representation. After reviewing the latest definitions of GERD and refractory GERD in the published literature, the SB collectively devised a practical definition of SSc refractory-GERD. Initial recommendations were drafted/agreed upon by the SB based on review of the existing guidelines, published literature, and expert opinion. Two online voting rounds were conducted to determine whether items should be accepted, with >75% and >60% SB agreement required for first and second rounds, respectively.

Results: There was a good response/completion rate for the initial (74%) and final (84%) voting rounds. The SB agreed on all 36 draft recommendations. The majority (n=34) were approved in the first round. Recommendations were organized according to the following categories: general approach to management (n=5), assessment (n=6), non-pharmacological (n=2) and pharmacological (n=10) management, endoscopic and surgical treatment (n=3), and special circumstances, including refractory GERD and SSc-ILD (n=3), myositis and SSc CTD-overlap (n=3) and peri-lung transplant (n=4).

Conclusion: The group of experts has drafted extended and practical recommendations for the management of SSc refractory-GERD. The necessity of a structured approach and a patient assessment is highlighted in order to provide a multi-disciplinary approach to the tailored choice of the treatment. Our work also has also identified significant unmet needs and has provided a research agenda to advance the field.