Calabrese et al asymptomatic and/or sustain esophageal healing (Earnest and Robinson 1999; Katz 1999). The proportion of patients remaining in remission is very low at only 10%–25%, after six months of therapy (Dent et al 1999). Patients with NERD experience relapse over 6 months, and in more severe cases of erosive esophagitis (particularly Los Angeles classiﬁcation grades C and D), relapse rate has been calculated between 80%–90% (Ollyo et al 1993; Lieberman 1987; Venables et al 1997b; Hetzel et al 1998; Sandmark et al 1998; Richter et al 2004). Due to this marked tendency towards relapse, almost all patients with GERD, regardless of endoscopic status, need an effective long-term management strategy for adequate symptom control, maintenance of mucosal healing, prevention of complications, and improvement of quality of life. Particularly, a maintenance therapy on a daily basis has been advocated in patients with severe esophagitis. Reports indicate that long-term therapy with appropriate PPI maintenance doses can be effective in as many as 100% of GERD patients (Katz 1999). Recently acid-suppressive therapy ‘on demand’ has been proposed as an alternative to maintenance therapy; the patients decide when to start and to stop treatment. In this way the therapeutic strategy is likely to be more cost-effective than day by day maintenance therapy. Otherwise, the few data published to date regards only patients with grades A–B esophagitis (Bardan et al 1999; Kaspari et al 2005; Scholten et al 2005). Johnsson and colleagues (2002) suggested that it is the patient’s habits more than symptoms that determine the frequency and interval of medication intake since the patient could not ﬁnd any correlation between the severity of the disease and medication intake. Several studies, and in particular, Venables and colleagues (1997a) who evaluated nearly 1000 patients (32% with erosive esophagitis), report that neither the physician evaluation nor a validated questionnaire that segregated patients into mild, moderate, or severe symptoms were predictive of erosive esophagitis (Venables et al 1997a; Devault 2006). ‘On demand therapy’ can be inadequate if the severity of the disease is not well documented because of the unpredictability of its course. There is no consensus or agreed deﬁnition on what constitutes long term PPIs prescription. The deﬁnition has varied: from one repeated prescription over 12 months to continuous therapy for periods ranging from 4 to >12 months (Table 1) (Ryder et al 1994; Roberts and Bateman 1995; Rubin et al 1995; Goudie et al 1996; Ahnfeldt-Mollerup et al 1997; Boutet et al 1999; Hungin et al 1999; Prach et al 1999; Vetvik and Straand 2001; Hurenkamp et al 2002; Chen et al 2003; Jacobson et al 2003; Majumdar et al 2003; Lassen et al 2004; Raghunath and Hungin 2004; Tsai et al 2004; Raghunath et al 2005). GERD is a very common complaint when considering the management of treatment with PPIs in the population over 65 years of age. GERD is usually more severe in the elderly than in younger patients and is frequently under-diagnosed and under-treated. Although there are a number of published articles reviewing the relative merits and limitations of the various therapy options for relapsing GERD, relatively few of them have speciﬁcally considered the elderly. In particular, there has been concern about the effects of different PPIs when coadministered with other drugs, such as benzodiazepin, warfarin, and digoxin, which are frequently used by older subjects. Efﬁcacy, safety, and tolerability of pantoprazole Pantoprazole is a PPI that has been evaluated in more than 100 clinical trials (van Zyl et al 2004). It is a substituted benzimidazole derivative. Pantoprazole has a higher chemical stability at neutral and moderately acidic pH compared with other PPIs, which makes it less likely to become activated in moderately acidic compartments of the body. Most importantly, it has a low potential for metabolic interactions with cytochrome P450-dependent oxidase system and so it is particularly suitable for patients in co-medications (Stupnicki et al 2004). Orally administered pantoprazole is very effective in GERD and achieves high healing rates as well as successful relief of symptoms (van Zyl et al 2004). Bardhan and colleagues (2005) reported that most patients need only the standard dose of 40 mg and healing occurs within 4 weeks in the vast majority. Otherwise, a maintenance treatment is advocated because of the high incidence of relapse of esophagitis. Prolonged pantoprazole therapy, also lasting up to 5 years, is also effective for the long term management of severe ulcers and reﬂux disease (Bardhan et al 2005). A particular concern regards GERD and its association with extra-esophageal complications and in particular with intrinsic asthma. In this case a high-dose long-term PPI treatment has been advocated. A recent study (Calabrese, Fabbri, et al 2005) showed that mild persistent asthma, besides having a highly prevalent relation with GERD, improves till a complete regression with 80 mg/daily for 6 months of pantoprazole. Twelve months follow up was carried out in this work. A possible occurring of a relapse 86 Clinical Interventions in Aging 2007:2(1)