care setting in the US, as many as 20% of older patients report acid reﬂux (Mold et al 1991). In a Japanese study, the prevalence of reﬂux esophagitis in patients aged >70 years was more than triple the prevalence in patients younger than 39 years (Maekava et al 1998). Interestingly, there are signiﬁcant differences between elderly and younger patients in the presentation of GERD. Older subjects with GERD are less likely to report frequent or severe heartburn and the majority do not experience acid regurgitation (Raiha et al 1991). Dysphagia usually occurs in the setting of long standing heartburn with slow progressive dysphagia for solid and rarely for liquids. Weight loss is infrequent because appetite is unchanged, which helps distinguish this usually benign dysphagia. This symptom is usually correlated to a peptic stricture, severe peristaltic dysfunction, and sometimes the ﬁrst presentation of Barrett’s esophagus with cancer (Raiha et al 1992). Extraesophageal presentation of GERD are more common in the elderly (Raiha et al 1992). The chest pain produced by acid reﬂux may be identical in quality to angina, making an appropriate diagnosis a difﬁcult problem. Because of this different symptom profile of GERD in the elderly, the disease, particularly in the milder form, may remain undiagnosed and untreated for a long period of time. The management of GERD in the older patient poses special challenges. GERD among older people shows a higher incidence of severe esophagitis and of its complications, ie, bleeding, stenosis, and Barrett’s esophagus. The disease presentation is more severe despite milder symptoms because of the cumulative injury of acid reﬂux over many years. A large epidemiological study from the US reported that age was an important risk factor for the development of severe forms of GERD, together with male gender, white ethnicity, and hiatus hernia (el-Serag and Sonnenberg 1997). Collen and colleagues (1995) noted that 81% of GERD patients aged 60 years or older developed erosive esophagitis compared with 47% of those younger than 60 years with GERD. Some other factors related to the development of GERD in the older patient are: a greater degree of nocturnal and supine reﬂux; the increased prevalence of hiatus hernia; reduced patient mobility and increased recumbence; altered gastrointestinal mobility; decreased saliva volume and bicarbonate secretion; and increased prevalence of co-morbid conditions affecting esophageal tone (ie, diabetes, cerebro- vascular accident, Parkinson’s disease, and increased usage of concomitant medication) (Mold et al 1991; Hungin et al 1999). Clinical Interventions in Aging 2007:2(1) Management of GERD in the elderly with pantoprazole The management of long-term treatment is a major point of interest because of the high occurrence of relapse after cessation of therapy. In fact, symptoms and esophagitis recur quickly if therapy is not continuative and long-term treatment appears to be the key to effective management. The intermittent use of antacids, alginic acid, or H2 receptor antagonists are usually helpful in relieving mild symptoms, if present, but do not heal esophagitis. Continuous PPI therapy is particularly useful in elderly patients with GERD to obtain a profound acid inhibition and to maintain complete symptom relief and healing of esophagitis. A placebo- controlled clinical trial demonstrates that maintenance therapy with pantoprazole 20 mg daily is an effective measure for minimizing the occurrence of relapse in patients over 65 years of age (Maekava et al 1998). In the maintenance period of the study, 80% of patients treated with placebo had an esophagitis relapse compared with 30% of patients who continued active treatment. Moreover, the study reports an intention-to-treat healing of 80% after 12 months of treatment with 20 mg of pantoprazole, which conﬁrms that this low dosage is sufﬁcient to reduce relapse. Interestingly, 76% of patients were affected by concomitant diseases and 65% were taking other drugs concomitantly with pantoprazole in this population. The low adverse reactions and relapse rates conﬁrmed that pantoprazole interacted minimally with other drugs and suggested that it could be used successfully in patients with multiple therapies. Another study indicates that esophagitis relapse rates in elderly who were not treated with maintenance therapy were constant during three years of follow up (relapse rates of 65.5%, 63.6%, and 57.1% after 1, 2, and 3 years respectively) (el-Serag and Sonnenburg 1997). A recent study focused on the managing of GERD in the elderly and posed the question about the better dosage to prevent relapse of heartburn compared with placebo (Hungin et al 1999). The study suggests that the most effective therapy is a full dose PPI than a low dose (average relapse rate with low dose was 28% and 13% with full dose). Instead, a study by Escourrou and colleagues (1999) suggests a maintenance therapy with pantoprazole 20 mg daily for six months to prevent relapse of reﬂux esophagitis and shows that it is at least equivalent to the 40 mg dose. It is without doubt that besides the necessity of a long-term treatment in the elderly with GERD, there is no general consensus on the optimal dosage. An important problem is the interaction of PPIs with other drugs. It is known that the interaction occurs through 89