Perspectives in Primary Care Clinical Cases: Gastroesophageal Reflux Disease

Transcription

1 VOLUME 1 AUGUST 2004 Perspectives in Primary Care Clinical Cases: Gastroesophageal Reflux Disease Case 1: 74-Year-Old Male Burning in chest, worsening at night Former smoker Taking calcium channel blocker and diuretic for hypertension Mildly elevated lipid levels, not medicated Case 2: 35-Year-Old Female Chronic non-productive cough Occasional mild sore throat in the morning Mild seasonal allergies No other complaints EXPERT PANEL Richard L. Corson, MD, FAAFP Program Director, Somerset Family Medicine Residency Vice President, Family Medicine and GME Somerset Medical Center, Somerville, NJ David Greenwald, MD, FACG GI Fellowship Program Director Associate Division Director Division of Gastroenterology Montefiore Medical Center, Bronx, NY SPONSORED BY This project is sponsored by an educational grant from AstraZeneca.

2 AUTHORS AND FACULTY Richard L. Corson, MD, FAAFP Program Director, Somerset Family Medicine Residency Vice President, Family Medicine and GME Somerset Medical Center Somerville, NJ Dr. Corson declares that in the last 12 months he has not had a financial interest, arrangement, or affiliation with any corporate organization. David Greenwald, MD, FACG GI Fellowship Program Director Montefiore Medical Center Bronx, NY Dr. Greenwald declares that in the last 12 months he has served on the Speakers Bureaus for AstraZeneca, Tap, Wyeth, and Janssen. CONTINUING MEDICAL EDUCATION STATEMENT AND CREDIT This activity has been reviewed and is acceptable for up to 1 prescribed credit hour by the American Academy of Family Physicians. Term of approval is for one year from the beginning distribution date of August 2004, with option to request yearly renewal. Credit may be claimed for one year from the date of this issue. Prescribed credit is equivalent to AMA Category 1 credit for purposes of the American Medical Association Physician Recognition Award and is earned and reported on an hour-per-hour basis. This logo designates clinical content that conforms to AAFP criteria for evidence-based continuing medical education (EBCME). EBCME is presented with practice recommendations supported by evidence that has been systematically reviewed by an AAFP-approved source. ACKNOWLEDGEMENT Perspectives in Primary Care Clinical Cases: Gastroesophageal Reflux Disease is supported by an educational grant from AstraZeneca. Special thanks to Wendy Horn PhD, Insight Communications Group LLC and Theresa Barrett, MS, New Jersey Academy of Family Physicians, for their invaluable assistance in preparing these clinical cases. Perspectives in Primary Care Clinical Cases 2004 New Jersey Academy of Family Physicians. This publication is available online at CASE STUDY LEARNING GOALS CASE 1 74-Year-Old Male With Burning in Chest, Hypertension, Mildly Elevated Lipids Gastroesophageal reflux disease (GERD) is a chronic condition, which is common in the elderly, and its presentation is different than that in the younger patients. The elderly are more susceptible to severe and complicated GERD. An elderly patient with symptoms of this chronic disease: heartburn, regurgitation or dysphagia, can develop serious implications if left untreated. In reviewing this case, family physicians will understand that GERD is less symptomatic and more severe in older patients and will develop a protocol for treating, referring and following up elderly patients with GERD. 2 CASE 2 35-Year-Old Female With Chronic Cough, Mild Sore Throat GERD, asthma, and postnasal drip are three of the most common causes of chronic cough in all age groups. In prospective adult studies, GERD, either alone or in combination with other diseases, contributes to cough, with frequencies ranging from 8% to 40%. In up to 75% of patients with GERD, chronic cough is the only presenting symptom and is often difficult to diagnose. More than half of the persons with cough due to GERD are unaware of reflux; they do not complain of typical gastrointestinal symptoms such as heartburn, sour taste, or regurgitation. A full medical examination and laboratory tests may be necessary to arrive at a correct diagnosis and effective treatment.

3 CASE 1 74-Year-Old Male With Burning in Chest, Hypertension, Mildly Elevated Lipids Learning Objectives After the completion of this case the family physician will 1) Understand that elderly patients with GERD may present with different symptoms than that of a younger patient with GERD. 2) Identify symptoms that are more common in elderly patients with GERD than in younger patients. 3) Develop a diagnostic approach for the treatment of GERD in the elderly which depends on the signs and symptoms with which the patient presents. 4) Understand that severe erosive esophagitis may be present in the elderly even in the absence of heartburn. 5) Demonstrate an understanding of how to work with the sub-specialist in the management of a patient with GERD in order to ensure continuity of care. 6) Understand current treatment options for elderly patients with GERD. Patient Profile: A 74-year-old Caucasian male recently moved to a continuing care center in the area and came to the Family Medicine Center for the first time. Although he had no complaints initially, upon questioning he admitted to some burning in the chest that had started some months ago, and seemed worse at night. He indicated that he had not mentioned this to his previous physician, who had treated him for hypertension. He reported elevated lipid levels, but did not want medication for this condition. He had no other significant complaints. PAST HISTORY No major illnesses No surgeries SOCIAL HISTORY CONCOMITANT Married MEDICATIONS Stopped smoking Calcium channel blocker 15 years ago Hydrochlorothiazide Glass of red wine with Aspirin (81 mg) dinner each evening Multivitamins CURRENT VISIT This was his first visit. Following a medical history and physical exam, blood was drawn for lab tests. An electrocardiogram was conducted, revealing regular sinus rhythm. Results of a dipyridamole/thallium stress test were normal. An echocardiogram revealed an LV ejection fraction of 56%. PHYSICAL FINDINGS ON EXAM Height: 5 6 Weight: 182 lbs. BP: 142/88 Pulse: 87 HEENT: Normal Lungs: Clear to A & P Heart: Regular with grade 2/6 systolic murmur at the left sternal border Abdomen: Soft, non-tender, normoactive bowel sounds Rectal Exam: Moderately enlarged prostate, no occult blood in stool Remainder of exam unremarkable LAB VALUES CBC: Normal Hb: 12.1 g Lipid Profile: TC: 220 mg/dl LDL: 160 mg/dl HDL: 38 mg/dl DECISION TO REFER The family physician considered a differential diagnosis that included angina, GI motility disorders, pulmonary pathology, and gastroesophageal reflux disease (GERD). Once cardiovascular disease was excluded in this older patient, it was important to focus on structural diseases, and, as always, there was a concern about malignancy. The patient was then referred for a GI consultation and probable endoscopy. REFERRAL TO THE GI SPECIALIST Early endoscopy is an important diagnostic tool in the older patient. An upper endoscopy revealed erosive esophagitis and a small hiatus hernia. Biopsy confirmed the esophagitis. SPECIALIST DIAGNOSIS AND TREATMENT PLAN The GI specialist confirmed the diagnosis of esophagitis using endoscopy. Lifestyle modifications and medication were recommended, as were weight loss and an exercise program. The patient was instructed to avoid recumbence when his stomach was full. He received a prescription for a proton pump inhibitor, to be taken once daily 30 minutes prior to breakfast. FOLLOW-UP The patient was asked to return to the specialist in eight weeks. In a consultation report to the family physician, the specialist indicated his findings and questioned whether the calcium channel blocker previously prescribed for hypertension might be having an adverse effect on the patient s symptoms. GERD IN THE ELDERLY Symptoms and Diagnosis The estimated lifetime prevalence of GERD in the US is 25 to 30%. 1 A Gallup survey found that 22% of those over 50 years of age used antacids and other antidyspeptic agents at least two times per week, compared with 9% of those less than 50 years. 2 Still, studies have yielded conflicting results as to whether GERD is more common in the elderly. 2 This may be due to the fact that certain symptoms may be more or less prominent in the elderly than in younger patients. 3 For example, while many younger patients with GERD complain of heartburn or acid regurgitation, elderly patients with GERD may 3

4 Elderly patients may have more severe reflux, with less severe symptoms. Table 1: Certain symptoms are more common in elderly patients with GERD than in younger patients. More Common Symptoms Chest pain Abdominal pain Respiratory symptoms Dysphagia Vomiting Less Common Symptoms Heartburn Regurgitation Figure 1: Early endoscopy is essential in the primary evaluation of elderly patients with new-onset GERD in order to diagnose potential: Barrett s esophagus Erosive esophagitis Strictures Malignancy present with abdominal or chest pain, vomiting, or respiratory symptoms such as cough (Table 1). Further, elderly patients with GERD perceive the symptoms as being much less severe, perhaps due to loss of sensory function with aging. 3 There is some evidence that heartburn, but not acid reflux, declines with age, suggestive of a decrease in sensory function and perception of 4, 5, 6 visceral pain associated with aging. The risk of complications appears to be greater in elderly patients, supporting the observation that severe erosive esophagitis may be present even in the absence of heartburn. A post-hoc analysis of data from five prospective clinical trials of nearly 12,000 patients with GERD found that severe esophagitis was significantly more common in patients over 70 years of age than in younger patients (p<0.0001), but that heartburn was less common in these older patients; age and severe heartburn were negatively associated (p<0.001). A meta-analysis of endoscopically confirmed erosive esophagitis confirmed that ulcers were present in a high proportion of asymptomatic patients. 7 Another study reported erosive esophagitis in 81% of GERD patients over the age of 60, compared with 47% in patients less than 60 years of age. 8 The concern that severe disease may be present in the absence of severe symptoms makes early endoscopy, an aggressive approach, an essential part of the initial evaluation of elderly patients with new onset GERD. Endoscopy allows the diagnosis of serious conditions that may be present, and is the technique of choice for evaluating the esophageal mucosa (Figure 1). 9 Symptoms such Table 2: Lifestyle modifications are often very helpful for elderly patients with GERD. 9 Avoid recumbancy on a full stomach: Don t nap after lunch. Wait 3 hours after the final meal of the day to go to bed. Elevate patient s head when sleeping by elevating the head of the bed at least 6 inches, or placing a 10-inch foam rubber wedge under the head. Dietary Recommendations: Obese patients should lose weight. Decrease dietary fat intake. Avoid irritants such as citrus, tomato products, coffee, and alcohol. Take care not to restrict intake to the point of undesired weight loss or malnutrition. Other Recommendations: Avoid smoking. Intermittent use of antacids, alginic acid, or over the counter H2-receptor antagonists and proton pump inhibitors (PPIs) is appropriate. as dysphagia, weight loss, bleeding, chest pain and choking require heightened attention. 9 Treatment of GERD in the Elderly Once GERD is diagnosed, lifestyle modifications and pharmacologic intervention provide effective treatment. There are many patient-directed lifestyle changes that can be instituted to good effect (Table 2). Older patients may view such changes favorably, particularly those who are already taking many other medications and those with a limited medication budget. In addition to lifestyle changes, it is important to review all medications that the patient is taking because they may contribute to reflux or esophageal symptoms (Table 3). 4 Pharmacologic intervention using proton pump inhibitors is usually necessary in addition to lifestyle modifications. These agents have become a mainstay in the treatment of GERD. Following the acute phase of treatment, maintenance therapy with proton pump inhibitors is necessary to avoid recurrence according to an outcomes assessment commissioned by the Canadian Coordinating Office for Health and Technology Assessment. 11 In addition to recurrence, prolonged exposure to acid may result in serious sequelae including ulcers, strictures, and Barrett s esophagus. 12 It is also important to consider that elderly patients may require more significant acid suppression to promote esophageal healing than do younger patients, making proton pump inhibitors an 8, 13 important part of therapy.

5 Table 3: Certain medications may contribute to esophageal symptoms. 10 Associated with increased reflux: Calcium channel blockers Estrogens Theophylline Associated with pill-induced esophagitis: NSAIDs* Tetracycline Potassium Alendronate *Nonsteroidal anti-inflammatory medications Therefore, more aggressive diagnosis and/or treatment of gastroesophageal reflux disease may be warranted for elderly patients, regardless of the reported severity of their presenting symptoms of heartburn. [JOHNSON, 2004 #5] EB-CME Practice Recommendations: 1) Endoscopy - In a patient over the age of 50, new onset of GERD is an alarm sign and endoscopy should be the initial diagnostic examination. [B] Available at: (p. 8) Last Accessed: June 10, ) Lifestyle Modifications - Lifestyle modifications should be recommended throughout the treatment of GERD but there is little evidence to support this information. [D] 3) Pharmacologic Treatment - Histamine type-2 (H2) receptor antagonists, past prokinetics and proton pump inhibitors (PPIs) have shown efficacy in the treatment of GERD with PPIs having faster healing rates in the treatment of erosive esophagitis. [A] 4) Documented Erosive Esophagitis - Initial proton pump inhibitor (PPI) therapy is the treatment of choice in acute and maintenance therapy for patients with documented erosive esophagitis. [A] 5) Proton Pump Inhibitors - Proton pump inhibitors (PPIs) should be given 30 to 60 minutes prior to a meal to optimize effectiveness. [B] Available at: =2598&string=gastroesophageal+AND+reflux+AND+disease Last Accessed: June 10, 2004 CASE 2 35-Year-Old Female with Chronic Cough, Mild Sore Throat Learning Objectives After the completion of this case the family physician will 1) Understand that GERD, asthma, and postnasal drip are the three most common causes of chronic cough. 2) Understand it is common for patients to present with GERD who are asymptomatic except for cough or hoarseness. 3) Develop a differential diagnosis protocol to identify those patients who are candidates for further testing for GERD. 4) Understand that patients presenting with ENT manifestations of GERD may take up to six months to heal. 5) Understand that physician and patient will need to work together to maintain the prescribed course over the long term with both understanding that GERD is a chronic condition, requiring continuous therapy to control symptoms as well as prevent complications. Patient Profile: A 35-year-old female systems analyst presented at the Family Medicine Center with a chronic, non-productive cough of 2 to 3 months duration. She mentioned occasionally having a mildly sore, scratchy throat in the morning. The patient reported taking over-the-counter medications for mild seasonal allergies; the medications provided good relief. She was a non-smoker who worked with smokers. The patient had no other complaints. She indicated that she only sees a physician for regular gynecological care and only began doing so following the delivery of her first child. PAST HISTORY No active illnesses No recent upper respiratory illness SOCIAL HISTORY Married, one child Exercises regularly Non-smoker, works with smokers CONCOMITANT MEDICATIONS OTC cold medications for seasonal allergy CURRENT VISIT Patient is presenting for the first time. Based on history and exam, the family physician began therapeutic trials of an antihistamine and a nasal corticosteroid. These had no effect. Similarly, adding a humidifier to the bedroom environment had no effect. The patient returned after several weeks, and was still coughing. 5

6 PHYSICAL FINDINGS ON EXAM Height: 5 6 Weight: 128 lbs. BP: 116/72 Pulse: 60 Resp: 16 Lungs: Clear Heart: Normal without murmur or gallop Ears: Normal Nose: Minimal erythema, otherwise normal Pharynx: Tonsils absent, otherwise normal Neck: Normal Otherwise, completely normal exam DECISION TO REFER The family physician had several initial diagnostic considerations, including the presence of allergy, postnasal drip, or bronchospasm. To rule out cough variant asthma, the family physician referred the patient for pulmonary function tests, and prescribed the inhaled -agonist, albuterol. All tests were normal. The patient returned in two weeks, still coughing. Once allergic and pulmonary etiologies were ruled out, the most likely cause was thought to be reflux. The family physician decided to begin a course of therapy with a proton pump inhibitor, and asked the patient to return in one month. At the end of the course of treatment the patient stated that she did not feel any better and she was referred to a GI specialist for consultation. REFERRAL TO THE GI SPECIALIST SPECIALIST DIAGNOSIS The GI specialist agreed with the presumptive diagnosis of GERD, and ordered an endoscopy to confirm the diagnosis. However, the result of the endoscopy showed no mucosal damage. Still suspecting GERD, the GI specialist ordered a ph study using a 24-hour ambulatory ph monitor. The ph study was done, and the patient was found to have 186 episodes of reflux over 24 hours, with an esophageal ph <4 during these episodes. Eighty percent of the episodes occurred at night. TREATMENT PLAN Therapy with a proton pump inhibitor was still considered the best course of treatment. The GI specialist instructed that the patient continue with the PPI, with the medication to be taken once daily 30 minutes prior to the first meal of the day. A report was sent to the family physician that included the ph study results as well as the recommendation for ongoing daily proton pump inhibitor therapy. Specialist follow-up was scheduled in three months. FOLLOW-UP The patient returned to the family physician in 4-6 weeks, reporting that she did not yet feel better. The family physician asked for more specifics concerning how the patient was feeling, asked if she had any side effects, and reminded the patient to keep taking the medication because it was not uncommon for GERD related ear, nose, and throat symptoms to take several months to respond to PPI therapy. The patient expressed concerns about long-term use of proton pump inhibitors, based on an Internet search. The family physician was able to reassure her based on long-term safety and tolerability data. GERD AND COUGH GERD, asthma, and postnasal drip are the three most common causes of chronic cough. 11 A consensus report delivered by the American College of Chest Physicians indicated that cough is the only symptom of GERD in up to 75% of cases. 14 Cough is thought to be a result of transient loss of tone in the lower esophageal sphincter. 11 Coughing further aggravates the loss of tone, producing a self-perpetuating cycle of reflux, irritation, and cough. 11 DIAGNOSIS It is common for physicians to see patients with GERD who are asymptomatic except for cough or hoarseness. Allergies and asthma can be considered and confirmed or ruled out based on patient history and medical examination (Figure 2). Ambulatory ph testing is recommended for confirmation that reflux is present in patients who have symptoms such as cough but no evidence of mucosal damage or cardiac pain. 9 Upon confirmation of esophageal reflux, lifestyle modifications and pharmacologic therapy can be recommended. TREATMENT OF COUGH-ASSOCIATED GERD Several lifestyle changes can be recommended, including smoking 6 cessation, weight reduction if necessary, and reducing intake of acidic foods. 11 Medication trials, including the use of a proton pump inhibitor, are also important in the management of cough-associated GERD. 11 The GERD treatment guidelines of the American College of Gastroenterology state that Proton pump inhibitors provide rapid symptomatic relief and healing of esophagitis in the highest percentage of patients. 9 However, full recovery may take up to six months in patients with ENT manifestations of GERD, requiring physician and patient to maintain the prescribed course over the long term. 15 Patients should also understand that GERD is a chronic condition, requiring continuous therapy to control symptoms as well as prevent complications. 9 Patients can be reassured that the longest-term study of safety and tolerability of a proton pump inhibitor found no increase in the incidence of adverse events during 6.5 years of treatment, and no unexpected adverse events. 16 Maintenance therapy is indicated for the majority of patients who initially require therapy for acute GERD. 17 Further diagnostic testing may be warranted in patients with apparently uncomplicated GERD who do not respond to treatment. 9 EB-CME Practice Recommendations: 1) Ambulatory ph testing is recommended to confirm a diagnosis of GERD when cough is present in the absence of mucosal damage or pain. [B] 2) Initiate and continue various lifestyle modifications throughout the course of GERD therapy. It is reasonable to educate patients about factors that may precipitate reflux. [D] 3) The potential benefit of chronic PPI therapy in patients with chronic or complicated GERD generally outweighs any theoretical risk of adverse effects. [A] Available at: guideline/gerd.pdf Last Accessed: June 10, 2004

7 Ambulatory ph testing is recommended to confirm a diagnosis of GERD when cough is present in the absence of mucosal damage or pain. References [DEVAULT, 1999 #10] 1) Scott M, Gelhot A. Gastroesophageal reflux disease: Diagnosis and management. Am Fam Physician. 1999;59: ) A Gallup survey on heartburn across America. Princeton, NJ: Gallup Organization; ) Triadafilopoulos G, Sharma R. Features of symptomatic gastroesophageal reflux disease in elderly patients. Am J Gastroenterol. 1997;92: ) Locke G, Talley N, Fett S, et al. Prevalence and clinical spectrum of gastroesophageal reflux: A population-based study in Olmsted County, Minnesota. Gastroenterology. 1997;112: ) Fass R, Pulliam G, Johnson C, et al. Symptoms severity and oesophageal chemosensitivity to acid in older and young patients with gastro-oesophageal reflux. Age Ageing. 2000;29: ) Johnson D, Fennerty M. Heartburn severity underestimates esophagitis severity in elderly patients with gastroesophageal reflux disease. Gastroenterology. 2004;126: ) Caro J, Salas M, Ward A. Healing and relapse rates in gastroesophageal reflux disease treated with the newer proton-pump inhibitors lansoprazole, rabegrazole, and pantoprazole compared with omeprazole, ranitidine and placebo: Evidence from randomized clinical trials. Clin Ther. 2001;23: ) Collen M, Abdulian J, Chen Y. Gastroesophageal reflux disease in the elderly: More severe disease that requires aggressive therapy. Am J Gastroenterol. 1995;90: ) DeVault K, Castell D, and The Practice Parameters Committee of the American College of Gastroenterology. Updated guidelines for the diagnosis and treatment of gastroesophageal reflux disease. Am J Gastroenterol. 1999;94: ) Peterson K, Jaspersen D. Medication-induced oesophageal disorders. Expert Opin Drug Saf. 2003;2: ) Perras C, Otten N. Pharmaceutical management of gastroesophageal reflux disease. Ottawa, Canada: Canadian Coordinating Office for Health Technology; Issue ) Achem A, Achem S, Stark M, et al. Failure of esophageal peristalsis in older patients: Association with esophageal acid exposure. Am J Gastroenterol. 2003;98: ) Garnett W, Garabedian-Ruffalo S. Identification, diagnosis, and treatment of acid-related diseases in the elderly: Implications for long-term care. Pharmacotherapy. 1997;17: ) Irwin R, Boulet L-P, Cloutier M, et al. Managing cough as a defense mechanism and as a symptom: A consensus panel report of the American College of Chest Physicians. Chest. 1998;114(Suppl 2):S ) Pratter M, Bartter T, Akers S, Dubois J. An algorithmic approach to chronic cough. Ann Internal Med. 1993;119: ) Klinkenberg-Knol E, Nelis, F, Dent, J, et al. Long term omeprazole treatment in resistant gastroesophageal reflux disease: Efficacy, safety, and influence on gastric mucosa. Gastroenterology. 2000;118: ) Johanson J. Epidemiology of esophageal and supraesophageal and reflux injuries. Am J Med. 2000;108:99S-103S. Figure 2: The differential diagnosis for patients presenting with chronic cough in the absence of other symptoms includes ruling out allergy and asthma. Ambulatory ph testing can then confirm the presence of reflux. Allergy or asthma confirmed. Appropriate next steps consistent with diagnosis of allergy or asthma. CONCLUSIONS: HEARTBURN IS NOT THE ONLY INDICATOR OF GERD The lifetime prevalence of GERD is such that the family physician may find fully one-quarter of all patients presenting with this disease. While some patients may present with symptoms such as heartburn or regurgitation, other patients may present with symptoms more commonly associated with allergy and asthma, or perhaps no symptoms at all in the case of elderly patients. For patients who do have GERD, lifestyle changes and long-term therapy with a proton pump inhibitor may relieve symptoms and help avoid complications. 9 7 Patient presents with chronic cough as the only symptom. Medical history, physical examination, medication trials to look for allergy or asthma. Allergy and asthma ruled out. Consider GERD. Refer to specialist. Ambulatory ph testing for the presence of reflux. GERD confirmed. Recommend lifestyle changes and long-term therapy with a proton pump inhibitor. Family physician long-term follow up: remind patient it may take up to 6 months for full recovery.

8 CME Post Test Perspectives in Primary Care Clinical Cases Gastroesophageal Reflux Disease VOLUME 1 AUGUST 2004 In order to receive CME credit you must complete and submit the following post-test and evaluation. Name Address AAFP Member ID City/State/Zip Please send me the answers to the test Please send a letter of documentation for activity completion (nonmembers) One Credit Reported In the space provided, indicate whether each item is True (T) or False (F). 1) Elderly patients with GERD are frequently asymptomatic. 2) Endoscopy is not necessary for diagnosing GERD in the elderly. 3) Elderly patients with GERD may present with abdominal or chest pain, vomiting, or respiratory symptoms such as cough. 4) Most patients are able to self-diagnose GERD based on symptoms. 5) Older patients may require more acid suppression than younger patients. 6) Prior to screening for GERD, it is useful to rule out allergy, postnasal drip and bronchospasm in patients who present with cough. 7) GERD has important long-term complications. 8) Full recovery may take up to six months in patients with ENT manifestations of GERD 9) The American College of Chest Physicians indicated that cough is not the only symptom of GERD in up to 75% of cases. 10) Proton pump inhibitors are standard treatment for long-term maintenance of patients with GERD. Evaluation (Rating Scale: 5 is the highest rating, 1 is the lowest rating) Relevance of this topic to my practice: Clinical material was current and useful: Patient cases were useful and appropriate: Overall rating for this activity: What do you anticipate that you will do differently as a result of reading these case studies? What topics would you like to see Perspectives in Primary Care Clinical Cases address in future issues? CME ACCREDITATION PROCEDURES AAFP Members AAFP members wishing to obtain CME credit for completing this activity should read Perspectives in Primary Care Clinical Cases: Gastroesophageal Reflux Disease, complete the post-test and evaluation, indicate the number of credits you are reporting for this activity and submit the answer sheet to the NJAFP by mail or fax. If the form is returned by mail or fax, your CME hours will be posted for you. Please mail or FAX this test and evaluation to: New Jersey Academy of Family Physicians, 112 West State Street, Trenton, NJ FAX: Phone: Non-AAFP Members Physicians who are not members of the AAFP may request a letter documenting activity completion. To do so, please check the appropriate box on the post-test answer sheet and return it to the NJAFP. New Jersey Academy of Family Physicians 112 West State Street Trenton NJ RETURN SERVICE REQUESTED PRESORTED FIRST CLASS U.S. Postage PAID Lansdale, PA Permit No. 444