Medications for Acid Reflux Relief

Medical Treatment of Gastroesophageal Reflux Disease
GERD is such a common condition that most sufferers with mild symptoms carry out self-medication. Sufferers when first seen with symptoms of heartburn without obvious complications can reasonably be placed on 8 to 12 weeks of simple antacids before extensive investigations are carried out. In many situations, this successfully aborts the attacks. Sufferers should be advised to elevate the head of the bed; avoid tight clothing; eat small, frequent meals; avoid eating their nighttime meal shortly before retiring; lose weight; and avoid alcohol, coffee, chocolate, and peppermints, which may aggravate the symptoms. Alginic acid, used in combination with simple antacids, may augment symptomatic relief by creating a physical barrier to reflux as well as by acid reduction. Alginic acid reacts with sodium bicarbonate in the presence of saliva to form a highly viscous solution that floats like a raft on the surface of the gastric contents. When reflux occurs, this protective layer is refluxed into the esophagus and acts as a protective barrier against the noxious gastric contents. Medications to promote gastric emptying, such as metoclopramide, domperidone, or cisapride, are beneficial in early disease but of little value in more severe disease. The mainstay of medical therapy is acid suppression. Sufferers with persistent symptoms should be given hydrogen potassium PPIs, such as omeprazole. In doses as high as 40 mg per day, they can effect an 80% to 90% reduction in gastric acidity. This usually heals mild esophagitis, but healing may occur in only three fourths of sufferers with severe esophagitis. It is important to realize that in sufferers who reflux a combination of gastric and duodenal juice, inadequate acid suppression therapy may give symptomatic improvement while still allowing mixed reflux to occur. This can result in an environment that allows persistent mucosal damage in an asymptomatic sufferer. Unfortunately, within 6 months of discontinuation of any form of medical therapy for GERD, 80% of sufferers have a recurrence of symptoms. In sufferers with reflux disease, esophageal acid exposure is reduced by up to 80% with H2-receptor antagonists and up to 95% with PPIs. Despite the superiority of the latter class of drug over the former, emerging evidence suggests that periods of acid breakthrough still occur. This occurs most commonly at nighttime and is some justification for a split rather than a single dosing regimen. Sufferers with breakthrough reflux symptoms were studied while on omeprazole 20 mg b.i.d. and found that many of them were still refluxing. Intragastric pH monitoring in 28 healthy volunteers and 17 sufferers with reflux disease revealed that nocturnal recovery of acid secretion (more than1 hour) occurred in 75% of the individuals. Recovery of acid secretion occurred within 12 hours of the oral evening dose of PPI, the median recovery time being 7.5 hours. This is particularly pertinent because it is during the nighttime and early morning that asthma symptoms are most pronounced and that peak expiratory flow rate is at its lowest. There have been also shown that ranitidine 300 mg at bedtime is superior to omeprazole 20 mg at bedtime in preventing acid breakthrough. it was speculated to be due to the abolition of histamine-mediated acid secretion in the fasting state. Sufferers presenting for the first time with symptoms suggestive of GE reflux may be given initial therapy with H2 blockers. In view of the availability of these as over-the-counter medication, many sufferers will have already self-medicated their symptoms. Failure of H2 blockers to control the symptoms or immediate return of symptoms after stopping treatment suggests that either the diagnosis is incorrect or the sufferers had relatively severe disease. Endoscopic examination at this stage of the sufferer's evaluation provides the opportunity for assessing the severity of mucosal damage and the presence of Barrett's esophagus. Both of these findings on initial endoscopy predict a high risk for medical failure. A measurement of the degree and pattern of esophageal exposure to gastric and duodenal juice, with 24-hour pH and bilirubin monitoring, should be obtained at this point. The status of the LES and the function of the esophageal body should also be measured. These studies identify features that predict a poor response to medical therapy, frequent relapses, and the development of complications and include supine reflux, poor esophageal contractility, erosive esophagitis or a columnar-lined esophagus at initial presentation, bile in the refluxate, and a structurally defective sphincter. Sufferers who have these risk factors should be given the option of surgery as a primary therapy with the expectation of long-term control of symptoms and complications.