GERD

Gastroesophageal Reflux Disease (GERD)

  • GERD is a chronic condition
  • Mechanisms of action by which GERD may develop:  LES factors–decreased LES pressure, increased relaxation of LES, increased abdominal pressure, impaired esophagael clearance/salivation/mucosal defense, increased gastric acid secretion, delayed gastric emptying
    • Note:  H Pylori plays no role
  • Symptoms of GERD, including alert symptoms.
    • GERD leads to an overall decrease in a patient’s quality of life
    • Long-term complications:  Barrett’s esophagus (most serious, metaplastic change in epithelium from squamous to columnar leading to a 30-60x greater risk of adenocarcinomas) erosive esophagitis (may result in hemorrhage/perforation), strictures (narrowing of the esophagus potentially resulting in dysphagia–difficulty swallowing), dental erosions, pulmonary symptoms such as asthma, bronchitis, etc
    • Typical:  heartburn (most common), belching/throwing up, acidic taste in mouth
    • Atypical (extraesophageal) symptoms:  non-allergic asthma (1/2 of patients w/ asthma have GERD), chronic cough/wheezing, sore throat, dental erosions, noncardiac chest pain, PUD
    • ALARM symptoms (moderate-severe so need to consult doctor):  GI bleed, difficulty swallowing, choking, weight loss, anemia
  • Drugs which may increase or decrease LES pressure.
    • Meds that decreases LES pressure:  beta-blockers, anticholinergics, benzos, CCBs, narcotics, etc
    • Foods that decrease LES pressure:  chocolate, fatty foods, EtOH, etc
    • Direct irritants:  (take meds w/ a glass of water) ASA, NSAIDs, Fe, KCl, quinidine, bisphosphonates, spicy foods, tomato juice, coffee, OJ
    • Other aggrivating factors:  body positioning, tight fitting clothing, prego, some medical conditions
  • Medication choices for the treatment of GERD.
    • Antacids (Al, Ca, Mg) are used in conjunction w/ other acid suppressing agents (H2RAs/PPIs)
      • Used for Mild disease as needed drug therapy (fast onset of action)
      • Liquids work better than tablets due to their local contact
      • Don’t promote healing of esophagus
      • These may interact w/ certain drugs due to their chelating effects & the reduction in pH that result
    • H2RAs suppress acid & decrease the acidity of the refluxate
      • Don’t use max daily dose for more than 2 weeks
      • Used for mild GERD
      • All are approved & equally efficacious yet inferior to PPIs
      • SE of H2RAs: CNS issues especially in geriatrics, ppl w/ renal impairment are more susceptible, gynecomastia, affect absorption of drugs dependent on low gastric pH, cimetidine inhibits CYP
H2RA Medication

Conventional OTC Strength

Conventional Dose for GERD*

High Dose

Cimetidine (Tagamet HB)

200 mg

400 mg BID

400 mg QID or 800 mg BID

Famotidine (Pepcid AC)

10 mg

20 mg BID

40 mg BID

Nizatidine (Axid AR)

75 mg

75 mg BID

150 mg QID

Ranitidine (Zantac 75)

75 mg

150 mg BID

150 mg QID

  • * Conventional Doses will block 60-70% of 24-hour acid secretion
    • It should also be noted that divided doses of H2RAs are more effective at treating GERD than once daily QHS dosing

PPIs

Medication

Conventional Dose for GERD

Conventional Dose for Erosive Esophagitis (EE)

Omeprazole (Prilosec)

20 mg PO QD

40 mg QD or 20 mg BID

Lansoprazole (Prevacid)

15 mg PO QD

30 mg PO QD

Rabeprazole (Aciphex)*

20 mg PO QD

 

Pantoprazole (Protonix)

40 mg PO QD

40 mg PO QD

Esomeprazole (Nexium)

20 mg PO QD

40 mg PO QD

Deslansoprazole (Dexilant)**

30 mg PO QD

60 mg PO QD

*Don’t crush Rabeprazole (Aciphex)

** Deslansoprazole (Dexilant) is the only dual delayed release (DDR) formulation on the market

  • Notes:
    • All PPIs are SIMILAR in efficacy.
    • PPIs are selected based on considerations of adverse effects, onset of action and prescription plan coverage.
    • PPIs are more effective when they are taken 30-60 minutes before a meal
    • PPIs available IV:  Pantoprazole (Protonix), Lansoprazole (Prevacid), and Esomeprazole (Nexium)

Therapeutic treatment options

  • Endoscopy/biopsy can be used to diagnose complications of GERD (Barrett’s esophagitis, strictures, neoplasms)
    • Used preoperatively in patients over 45 who have alarm symptoms & are refractory to initial treatment
  • Manometry is used before a pH test to evaluate peristaltic dysfunction & rule out esophageal motility disorders
    • pH testing is done for patients w/ normal manometry, & no mucosal changes on endoscopy
      • Withhold PPIs for 7 days prior to pH testing
  • Goals of therapy:  improve quality of life (alleviate/eliminate symptoms), decrease reflux, heal mucosa, prevent complications
  • Stages of treatment:  lifestyle modifications –> OTCs –> scheduled drug therapy (PPIs, H2RAs) –> maintenance therapy –> surgery
  • Lifestyle modifications:  lose weight, quit smoking, avoid alcohol, elevate head of bed, smaller meals, avoid food 2-3 hours before bedtime
  • PPIs are the drugs of choice for moderate-severe GERD, refractory GERD, erosive esophagitis (EE) & complicated symptoms such as Barrett’s esophagitis, strictures
    • If the patient doesn’t have esophagitis then you can use either OTC agents or an H2RA
    • If they do have esophagitis, it may require long-term PPI therapy
    • Use PPIs for 4-8 weeks
    • PPIs are all equally efficacious
    • H2RAs are all equally efficacious
  • The prokinetic drug cisapride (propulsid) is no longer used as adjunct therapy due to its SE of arrhythmias
  • 2 surgery options:  Nissen fundoplication or partial fundoplication
    • Used if patient has severe esophagitis & PPIs failed, or bleeding from esophagitis or if have refractory extraesophageal symptoms

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