GERD and Its Treatment
Gastroesophageal reflux disease (GERD) is often associated with heartburn or indigestion, but in essence it is related to reflux of gastric contents. Gastroesophageal reflux is a physical condition in which acid from the stomach flows backward up into the esophagus. Patients experience heartburn symptoms when a disproportionate amount of acid refluxes into the esophagus.
Unfortunately, more than 60 million Americans experience heartburn or indigestion at least 2 or 3 times a week. Indigestion is a common inclusive term used to describe physical discomfort of the upper gastrointestinal (GI) tract, usually associated with drinking or eating. The symptoms include heartburn, acid indigestion, gaseous distention, flatulence, belching, fullness, pressure, nausea, and vomiting. Most people describe heartburn as a feeling of burning discomfort, localized behind the breastbone or sternum, which moves up toward the neck and throat. Some are aware of a bitter or sour taste of acid in the back of the throat. Patients having these symptoms at least 2 or 3 times a week may be diagnosed as having GERD.
To understand GERD, it is first necessary to be cognizant of the causes of heartburn. Many people will experience heartburn if the lining of the esophagus comes in contact with too much stomach fluid for a long time. The stomach fluid consists of 0.5% hydrochloric acid and digestive enzymes. The prolonged contact of stomach juice (acid) with the esophageal lining injures the esophagus and results in a burning sensation.
A muscular valve located at the lower end of the esophagus is called the lower esophageal sphincter (LES). Its function is to keep acid in the stomach and out of the esophagus. In GERD, the LES relaxes too frequently, allowing stomach acid to reflux, or flow backward into the esophagus. Pharmacists should be familiar with these symptoms and may need to direct the patient to a physician for further diagnosis and treatment (see Table for diagnostic tests).
Indigestion and heartburn occur frequently among elderly individuals and pregnant women. Pharmacists should be alert to patients who continually purchase OTC antacids. Pharmacists should be especially concerned about elderly persons who buy sodium bicarbonate. Although it neutralizes acidity temporarily, it also causes a rebound effect, thus producing additional acidity. Indeed, patients who attempt to self-treat their symptoms with OTC preparations often prolong their problems, and they often do not mention their indigestion to their physician.
Altering lifestyle and the selective use of OTCs can control less frequently occurring heartburn. People should avoid foods and beverages that contribute to heartburn: chocolate, coffee, peppermint, spicy or greasy foods, alcoholic beverages, and tomato-related foods. They should stop smoking, because tobacco inhibits saliva, which is the body?s major buffer. Tobacco also stimulates stomach acid production and relaxes the LES muscle, allowing reflux to occur.
When symptoms of heartburn are not controlled with modifications in lifestyle?and OTC medications are required more often than twice a week or symptoms remain unresolved with the medication the patient is taking?he or she should be referred to a physician.
Complications of GERD
When GERD is not treated, serious complications can occur, such as severe chest pain that can mimic that of a heart attack; esophageal stricture (a narrowing or obstruction of the esophagus); bleeding; or a premalignant change in the lining of the esophagus, called Barrett?s esophagus. Barrett?s esophagus is the most serious complication of chronic GERD, as the lining of the esophagus changes to resemble that of the intestine. This is a precancerous condition.
Symptoms suggesting that serious damage may already have occurred include the following:
- Dysphasia?difficulty swallowing or a feeling that food is trapped behind the breastbone (sternum)
- Bleeding?vomiting blood or having tarry black bowel movements
- Choking?a sensation of acid refluxed into the windpipe, causing shortness of breath, coughing, or hoarseness of the voice
Treatment Goals for GERD
GERD may be symptomatic by day, but much more damage can be done at nighttime. Treatment should be designed to (1) eliminate symptoms, (2) heal esophagitis, and (3) prevent the relapse of esophagitis or the development of complications in patients with esophagitis. In many patients, GERD is a chronic, relapsing disease that requires long-term maintenance therapy.
Treatment is essentially based on attempting to decrease the amount of acid that refluxes from the stomach back into the esophagus, or to make the refluxed material less irritating to the lining of the esophagus.
Medical Treatment of GERD
Pharmaceutical research has recently yielded a large number of drugs to manage GERD. They include histamine2 receptor antagonists (H2 blockers), GI stimulants, and proton pump inhibitors (PPIs).
Cimetidine, famotidine, nizatidine, and ranitidine all act competitively to inhibit the action of histamine2 at the receptor sites of the parietal cells, decreasing gastric acid secretion.
- Cimetidine?800 mg given orally at bedtime reduces the mean hourly histamine by >85%
- Famotidine?its primary clinically important pharmacologic activity is the inhibition of gastric secretion; the patient is required to take 10 mg before meals
- Ranitidine?symptomatic relief occurs within 24 hours after starting therapy with 150 mg bid
- Nizatidine?150 mg is indicated up to 12 weeks for the treatment of endoscopically diagnosed esophagitis, including erosive and ulcerative esophagitis, and associated heartburn due to GERD
Metoclopramide acts to stimulate the motility of the upper GI tract by increasing LES tone and blocking dopamine receptors at the chemoreceptor trigger zone. For symptomatic relief of GERD, the patient should take 10 to 15 mg metoclopramide orally up to 4 times a day 30 minutes before meals and at bedtime, depending on the symptoms being treated and the clinical response.
PPIs significantly heal erosive esophagitis, the most serious type of GERD, more speedily than histamine2 blockers. The newer drugs added to the armamentarium include omeprazole and esomeprazole.
Omeprazole 15 and 30 mg was recently made available as an OTC drug. It is a valuable and convenient drug, with a 24-hour duration of action if taken in the morning, providing relief for heartburn only. It inhibits the activity of the acid proton pump and binds to hydrogen- potassium adenosine triphosphatase (H+/K+ ATPase) located at the secretory surface of the gastric parietal cells to block the formation of gastric acid.
Esomeprazole is available by prescription. This drug is a delayed-release capsule that suppresses gastric acid secretion by specific inhibition of the H+/K+ ATPase in the gastric parietal cells. Esomeprazole 20 or 40 mg should be given daily in the morning and is indicated for the treatment of heartburn and for other symptoms associated with GERD.
All drugs have side effects, and these drugs are no exception. The side effects include headache, diarrhea, nausea, gas, stomach pain, constipation, and dry mouth. If any of these side effects persist, the patient?s physician should be informed.
Surgery is not indicated for all patients having GERD, but it is the ultimate- recourse form of treatment. Fundoplication surgery is used to eliminate reflux in patients with severe complications, particularly recurrent aspiration pneumonia.
With effective treatment, using the range of prescription medications and other treatments that are currently available, patients should become symptomfree. Patients also should avoid offending foods and medications, especially anticholinergic drugs, because they lower the sphincter pressure. Patients who follow these relatively simple steps should enjoy the quality of life they desire.