Behavioral Therapy for Functional Heartburn: Recommendation Statements

Livia Guadagnoli; Rena Yadlapati; John Pandolfino; Alyse Bedell; Anjali U Pandit; Kerry B Dunbar; Ronnie Fass; Richard Gevirtz; C Prakash Gyawali; Stephen E Lupe; Megan Petrik; Megan E Riehl; Jessica Salwen-Deremer; Madison Simons; Kathryn N Tomasino; Tiffany Taft

doi:10.1016/j.cgh.2024.03.004

Behavioral Therapy for Functional Heartburn: Recommendation Statements

Clin Gastroenterol Hepatol. 2024 Mar 20:S1542-3565(24)00285-4. doi: 10.1016/j.cgh.2024.03.004. Online ahead of print.

Authors

Livia Guadagnoli¹, Rena Yadlapati², John Pandolfino³, Alyse Bedell⁴, Anjali U Pandit⁵, Kerry B Dunbar⁶, Ronnie Fass⁷, Richard Gevirtz⁸, C Prakash Gyawali⁹, Stephen E Lupe¹⁰, Megan Petrik¹¹, Megan E Riehl¹², Jessica Salwen-Deremer¹³, Madison Simons¹⁰, Kathryn N Tomasino⁵, Tiffany Taft⁵

Affiliations

¹ Laboratory for Brain-Gut Axis Studies (LaBGAS), Translational Research Center for Gastrointestinal Disorders (TARGID), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven, Leuven, Belgium. Electronic address: Livia.guadagnoli@kuleuven.be.
² Center for Esophageal Diseases, Division of Gastroenterology & Hepatology, University of California San Diego, La Jolla, California.
³ Kenneth C. Griffin Esophageal Center, Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
⁴ Departments of Psychiatry & Behavioral Neuroscience and Medicine (Section of Gastroenterology, Hepatology, and Nutrition), The University of Chicago, Chicago, Illinois.
⁵ Division of Gastroenterology & Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
⁶ Division of Digestive Diseases, University of Texas Southwestern Medical Center and VA North Texas Healthcare System, Dallas, Texas.
⁷ Division of Gastroenterology and Hepatology, Case Western Reserve University, Cleveland, Ohio.
⁸ Clinical PhD Program, CSPP@Alliant International University, San Diego, California.
⁹ Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri.
¹⁰ Department of Gastroenterology, Hepatology, and Nutrition, The Cleveland Clinic, Cleveland, Ohio.
¹¹ Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota.
¹² Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan.
¹³ Departments of Psychiatry and Medicine (Section of Gastroenterology & Hepatology), Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire.

PMID: 38518891
DOI: 10.1016/j.cgh.2024.03.004

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.