Gastroesophageal reflux disease (GERD) occurs when stomach acid frequently backs up into the esophagus, and it is one of the most common gastrointestinal conditions.1

Common symptoms include chest pain, difficulty swallowing, heartburn, and regurgitation.1 Others may include cough, laryngitis, and wheezing, which can lead to trouble sleeping.2 Lifestyle modifications, such as avoiding food close to bedtime, elevating the head of the bed for sleeping, and maintaining a healthy weight, have been shown to reduce symptoms.2 A variety of OTC products, such as antacids, histamine H2 receptor antagonists (H2RAs), and proton pump inhibitors (PPIs), are available to help manage symptoms.1,2 The health care team can use a patient-centered approach to select the best ones.

TREATMENTS AND COUNSELING PEARLS
Antacids
Antacids such as aluminum hydroxide and magnesium hydroxide (Mylanta) and calcium carbonate (Tums) neutralize stomach acid and provide quick relief.1 However, the effects of antacids do not last as long as those of PPIs.2 Advise patients that aluminum and calcium products can cause constipation, and medications with magnesium can cause diarrhea.1 Patients with renal dysfunction should avoid antacids with magnesium, which can exacerbate the condition. They should also avoid aspirin-containing antacids because of an increased risk of intestinal bleeding and should always read the drug facts label to ensure that aspirin is not an active ingredient.3

H2RAs
H2RAs reduce acid production, but they do not work as quickly as antacids. However, H2RAs provide longer relief and may decrease acid production for up to 12 hours.4 Examples of OTC H2RAs include cimetidine (Tagamet HB), famotidine (Pepcid AC), and nizatidine (Axid AR). Cimetidine can increase warfarin levels, leading to an increased risk of bleeding.5 Therefore, patients should be encouraged to contact their health care providers before starting on OTC products for GERD, and individuals taking warfarin may need to select a different H2RA for symptom relief. These medications can be taken up to twice a day for symptom relief, and patients can start to feel the effects about 30 to 90 minutes after taking the drug.4 The H2RA ranitidine (Zantac) was withdrawn from the market at the request of the FDA, as the levels of N-nitrosodimethylamine (NDMA), a probable human carcinogen, found in the products may increase with temperature and time.6 Nizatidine oral solution, manufactured by Amneal Pharmaceuticals, also issued a nationwide recall of the product because of NDMA amounts that could potentially cause health risks.7 It is important to educate patients to stop using the nizatidine and ranitidine products that were recalled and withdrawn and switch to a different medication for GERD management. Long-term use of H2RAs can also cause vitamin B12 deficiency and checking levels along with supplementation may be necessary.1

PPIs
Evidence shows that the most effective therapies for GERD are PPIs, and OTC options include lansoprazole (Prevacid 24HR) and omeprazole (Prilosec, Zegerid). However, PPIs can take about 1 to 3 days after they are initiated for patients to experience clinically significant benefits.4 These drugs work by blocking acid secretion, and they can heal the esophageal mucosa. Evidence suggests that they are more effective than H2RAs for short-term treatment (14 days) of GERD symptoms, with effects lasting up to 10 weeks.4 Patients with symptoms lasting longer than 2 weeks should be referred to a physician for further evaluation. Advise patients to take PPIs once daily, 30 to 60 minutes before the first meal of the day.4 When taken long term, these medications can result in serious adverse effects, such as cardiovascular events, chronic kidney injury, Clostridioides difficile, magnesium and vitamin B12 deficiencies, osteoporosis, and pneumonia.8,9 Patients should use the lowest effective OTC PPI dose for 14 days of treatment up to 3 times per year.4,10 Clinical practice guidelines recommend deprescribing PPIs by reducing the dose, stopping, or using “on-demand” dosing in adults who have been taking PPIs for at least 4 weeks for GERD with resolved symptoms.10 Providers can help prevent serious adverse effects by using a patient-centered approach.4 One option is decreasing the daily dose or stopping and changing to as-needed use if symptoms still occur.10 Another option is switching to an H2RA instead of a PPI if symptoms relapse, as H2RAs have a lower risk of long-term adverse effects.10 
 
Jennifer Gershman, PharmD, CPh, is a drug information pharmacist and Pharmacy Times® contributor who resides in South Florida.





REFERENCES
  1. Gastroesophageal reflux disease (GERD). Mayo Clinic. Accessed April 19, 2020. https://www.mayoclinic.org/diseases-conditions/gerd/symptoms-causes/syc-20361940 
  2. Sandhu DS, Fass R. Current trends in the management of gastroesophageal reflux disease. Gut Liver. 2018;12(1):7-16. doi: 10.5009/gnl16615      
  3. Warning: aspirin-containing antacid medicines can cause bleeding. US Food & Drug Administration. Published June 6, 2016. Accessed April 20, 2020. https://www.fda.gov/consumers/consumer-updates/warning-aspirin-containing-antacid-medicines-can-cause-bleeding
  4. MacFarlane B. Management of gastroesophageal reflux disease in adults: a pharmacist’s perspective. Integr Pharm Res Pract. 2018;7:41-52. doi: 10.2147/IPRP.S142932
  5. Warfarin drug interactions. UW Medicine Pharmacy Services. Accessed April 22, 2020. https://www.depts.washington.edu/anticoag/home/content/warfarin-drug-interactions
  6. Questions and answers: NDMA impurities in ranitidine (commonly known as Zantac). US Food & Drug Administration. Published April 1, 2020. Accessed April 21, 2020. https://www.fda.gov/drugs/drug-safety-and-availability/questions-and-answers-ndma-impurities-ranitidine-commonly-known-zantac
  7. Amneal Pharmaceuticals, LLC. issues voluntary nationwide recall of nizatidine oral solution, 15 mg/mL, due to potential levels of N-nitrosodimethylamine (NDMA) impurity amounts above the levels established by FDA. US Food & Drug Administration. Published April 15, 2020. Accessed April 21, 2020. https://www.fda.gov/safety/recalls-market-withdrawals-safety-alerts/amneal-pharmaceuticals-llc-issues-voluntary-nationwide-recall-nizatidine-oral-solution-15-mgml-due
  8. Freedberg DE, Kim LS, Yang YX. The risks and benefits of long-term use of proton pump inhibitors: expert review and best practice advice from the American Gastroenterological Association. Gastroenterology. 2017;152(4):706-715. doi: 10.1053/j.gastro.2017.01.031
  9. FDA drug safety communication: low magnesium levels can be associated with long-term use of proton pump inhibitor drugs (PPIs). US Food & Drug Administration. Updated August 4, 2017. Accessed April 22, 2020. https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-low-magnesium-levels-can-be-associated-long-term-use-proton-pump
  10. Farrell B, Pottie K, Thompson W, et al. Deprescribing proton pump inhibitors: evidence-based clinical practice guideline. Can Fam Physician. 2017;63(5):354-364.