Acid Reflux (GERD)
Treatment
Phase 1
Lifestyle Changes
:
j
Lifestyle
Changes
k
Over the counter antacids
l
Foam barriers
m
Histamine antagonists
n
Pro-motility drugs
Phase 2 Medications Treatment :
j
Higher more frequent an H2 receptor antagonist
ranitidine, famotidine, cimetidine
k
Proton pump inhibitors
Phase 3 Surgery
:
j
Surgery
k
Endoscopy
l
Prevention of transient LES relaxation
Acid Reflux (GERD)
Treatment
Phase 1
:
Lifestyle Changes
j
Lifestyle
Changes
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Elevation of the upper body : reflux of acid is more injurious at night than during the day.
At night, when individuals are lying down, it is easier for
reflux to occur. The reason that it is easier is because gravity
is not opposing the reflux, as it does in the upright position
during the day.
In addition, the lack of an effect of gravity
allows the refluxed liquid to travel further up the esophagus
and remain in the esophagus longer. These problems can be
overcome partially by elevating the upper body in bed. The
elevation is accomplished either by putting blocks under the
bed's feet at the head of the bed or, more conveniently, by sleeping with the upper body on a
wedge. These maneuvers raise the esophagus above the stomach and
partially restore the effects of gravity. It is important that
the upper body and not just the head be elevated. Elevating only
the head does not raise the esophagus and fails to restore the
effects of gravity.
Elevation of the upper body at night generally is recommended
for all patients with GERD. Nevertheless, most patients with
GERD have reflux only during the day and elevation at night is
of little benefit for them. It is not possible to know for
certain which patients will benefit from elevation at night
unless acid testing clearly demonstrates night reflux. However,
patients who have heartburn, regurgitation, or other symptoms of
GERD at night are probably experiencing reflux at night and
definitely should use upper body elevation. Reflux also occurs
less frequently when patients lie on their left rather than
their right sides.
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Smaller, more frequent meals : First, the smaller meal results in lesser distention of the
stomach. Second, by bedtime, a smaller and earlier meal is more
likely to have emptied from the stomach than is a larger one. As
a result, reflux is less likely to occur when patients with GERD
lie down.
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Quit smoking
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Reduce caffeine intake
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Stress reduction
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Avoid foods that cause heartburn by (delaying gastric emptying
or increasing acid exposure) i.e. chocolate, onions, spearmint,
peppermint, fat, coffee, garlic, citrus juices
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Reduce alcohol intake
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Reduce fat intake
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Obtain ideal body weight
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Avoid lying down after meals
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Avoid exercising on a full stomach
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Avoid tight fitting clothes around the waist
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Chewing gum : One novel approach to the treatment of GERD is chewing gum.
Chewing gum stimulates the production of more
bicarbonate-containing saliva and increases the rate of
swallowing. After the saliva is swallowed, it neutralizes acid
in the esophagus. In effect, chewing gum exaggerates the normal
process that neutralizes acid in the esophagus. It is not clear,
however, how effective chewing gum actually is in treating
heartburn. Nevertheless, chewing gum after meals is certainly
worth a try.
k
Over the counter antacids
Despite the development of potent
medications for the treatment of GERD,
antacids remain a mainstay of treatment.
Antacids neutralize the acid in the stomach
so that there is no acid to reflux. The
problem with antacids is that their action
is brief. They are emptied from the empty
stomach quickly, in less than an hour, and
the acid then re-accumulates. The best way
to take antacids, therefore, is
approximately one hour after meals or just
before the symptoms of reflux begin after a
meal. Since the food from meals slows the
emptying from the stomach, an antacid taken
after a meal stays in the stomach longer and
is effective longer. For the same reason, a
second dose of antacids approximately two
hours after a meal takes advantage of the
continuing post-meal slower emptying of the
stomach and replenishes the
acid-neutralizing capacity within the
stomach.
Aluminum-containing antacids have a tendency
to cause constipation, while
magnesium-containing antacids tend to cause
diarrhea. If diarrhea or constipation
becomes a problem, it may be necessary to
switch antacids or alternately use antacids
containing aluminum and magnesium.
Over the counter antacids such as:
• Aluminum hydroxide
• Magnesium hydroxide
• Calcium hydroxide
• Sodium bicarbonate
l
Foam barriers
Foam barriers provide a unique form of
treatment for GERD. Foam barriers are
tablets that are composed of an antacid and
a foaming agent. As the tablet disintegrates
and reaches the stomach, it turns into foam
that floats on the top of the liquid
contents of the stomach. The foam forms a
physical barrier to the reflux of liquid. At
the same time, the antacid bound to the foam
neutralizes acid that comes in contact with
the foam. The tablets are best taken after
meals (when the stomach is distended) and
when lying down, both times when reflux is
more likely to occur. Foam barriers are not
often used as the first or only treatment
for GERD. Rather, they are added to other
drugs for GERD when the other drugs are not
adequately effective in relieving symptoms.
There is only one foam barrier, which is a
combination of aluminum hydroxide gel,
magnesium trisilicate, and alginate (Gaviscon).
Over the counter foaming agents:
• Alginic acid (Gaviscon)
• Sodium alginate (Gaviscon)
m
Histamine antagonists
Although antacids can neutralize acid, they
do so for only a short period of time. For
substantial neutralization of acid
throughout the day, antacids would need to
be given frequently, at least every hour.
The first medication developed for more
effective and convenient treatment of
acid-related diseases, including GERD, was a
histamine antagonist, specifically
cimetidine (Tagamet). Histamine is an
important chemical because it stimulates
acid production. Released within the wall of
the stomach, histamine attaches to receptors
(binders) on the stomach's acid-producing
cells and stimulates the cells to produce
acid. Histamine antagonists work by blocking
the receptor for histamine and thereby
preventing histamine from stimulating the
acid-producing cells. (Histamine antagonists
are referred to as H2 antagonists because
the specific receptor they block is the
histamine type 2 receptor.)
Because histamine is particularly important
for the stimulation of acid after meals, H2
antagonists are best taken 30 minutes before
meals. The reason for this timing is so that
the H2 antagonists will be at peak levels in
the body after the meal when the stomach is
actively producing acid. H2 antagonists also
can be taken at bedtime to suppress
nighttime production of acid.
H2 antagonists are very good for relieving
the symptoms of GERD, particularly
heartburn. However, they are not very good
for healing the inflammation (esophagitis)
that may accompany GERD. In fact, they are
used primarily for the treatment of
heartburn in GERD that is not associated
with inflammation or complications, such as
erosions or ulcers, strictures, or Barrett's
esophagus.
Over the counter H2 receptor antagonist:
• Ranitidine
• Famotidine
• Cimetidine
• Nizatidine
All four are also available over-the-counter
(OTC), without the need for a prescription.
However, the OTC dosages are lower than
those available by prescription.
n
Pro-motility drugs
Pro-motility drugs work by stimulating the
muscles of the gastrointestinal tract,
including the esophagus, stomach, small
intestine, and/or colon. One pro-motility
drug, metoclopramide (Reglan), is approved
for GERD. Pro-motility drugs increase the
pressure in the lower esophageal sphincter
and strengthen the contractions
(peristalsis) of the esophagus. Both effects
would be expected to reduce reflux of acid.
However, these effects on the sphincter and
esophagus are small. Therefore, it is
believed that the primary effect of
metoclopramide may be to speed up emptying
of the stomach, which also would be expected
to reduce reflux.
Pro-motility drugs are most effective when
taken 30 minutes before meals and again at
bedtime. They are not very effective for
treating either the symptoms or
complications of GERD. Therefore, the
pro-motility agents are reserved either for
patients who do not respond to other
treatments or are added to enhance other
treatments for GERD.
 Phase 2 Medications Treatment
;
Phase 3 Surgery
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