Treatment of GERD: Overview for Patients Colin W. Howden, MD Hyman Professor of Medicine and Chief, Division of Gastroenterology, University of Tennessee Health Science Center, Memphis, TN, USA Lifestyle modifications (LSMs) play a minor role in the management of heartburn 1. A number of LSMs have been recommended in the past including smoking cessation, dietary modifications etc. These often make sense from a general medical perspective but there is not much solid evidence that they substantially improve heartburn or other GERD symptoms. Of the various LSMs that have been studied, the best evidence is for weight reduction in the overweight and obese, and elevation of the head end of the bed while sleeping. However, the latter is seldom done because it is viewed as impractical. In many countries around the world, people with heartburn have access to over-the-counter (OTC) medicines that they can purchase without first seeing a physician. OTC medicines for heartburn may comprise antacids, H2-receptor antagonists (H2RAs) and proton pump inhibitors (PPIs) although not all of these may be available OTC in some countries. People with typical heartburn often use these medicines without seeing a doctor – or may use them before they see a doctor. Different countries’ regulatory agencies have made different recommendations about the use of OTC medicines for heartburn, so it would be wise to check on the situation in individual countries. In some countries, H2RAs and PPIs may still only be available with a doctor’s prescription and may not be available for OTC purchase. Antacids work quickly by neutralizing stomach acid that has come into contact with the lining of the esophagus. These medicines have been used for many years and are generally safe. If these medicines alone are sufficient to control a person’s heartburn, no further medical treatment may be necessary. They are suitable for people with mild intermittent heartburn, especially if it is triggered by over-eating. Antacids may contain aluminum, magnesium or calcium. Those with aluminum or calcium may cause constipation; those with magnesium may cause diarrhea. Otherwise, antacids are generally safe and without significant side effects. Sodium bicarbonate can be absorbed into the circulation. It should not be used repeatedly as it can cause sodium overload in some people (for example, those with heart, kidney or liver problems or high blood pressure). H2RAs were first developed in the 1970s to treat stomach ulcers. Since then, millions of patients worldwide have received these medicines, which are considered to be extremely safe 2. They work on the cells in the stomach that produce acid. H2RAs reduce the production of stomach acid. When less stomach acid is produced, there is less likelihood of acid-related heartburn. H2RAs in prescription or OTC doses may be effective for the treatment of heartburn in people with GERD. However, they are probably best suited for people who are having relatively mild heartburn – and not necessarily on a daily basis. The effectiveness of H2RAs on heartburn may reduce or wear off over time if they are taken on a regular daily basis 4. For that reason, some people find these drugs to be useful if taken only intermittently – and especially on occasions when a particularly large or heavy meal has been eaten. Examples of H2RAs (not all of which may be available in all countries) include cimetidine, ranitidine, famotidine and nizatidine. In both prescription and OTC forms, these may have different trade names in different countries. PPIs also work by reducing the amount of acid produced by the stomach. However, they work differently from the H2RAs and they reduce acid production by a greater amount. They are generally highly effective for treating heartburn that is due to reflux of stomach acid into the esophagus 2, 3. For most people, a PPI only needs to be taken once-daily; generally, these medicines are best taken 30 – 60 minutes before a meal. Some people take these medicines twice-daily if they do not get adequate heartburn relief from a once-daily dose. These medicines may take a few days to reach their maximum effect. Examples of PPIs that may be available for prescription use or OTC purchase include omeprazole, lansoprazole, pantoprazole, rabeprazole, esomeprazole and dexlansoprazole. Not all of these will be available in all countries and some that are available may not be for OTC purchase. The trade names of these medicines may vary among different countries. While PPIs are generally considered to be very safe drugs, there have been some recent safety concerns. Long term use of these drugs may be associated with a slight increase in the risk of bone fractures although the mechanism of this is unknown. People at risk of fracture (for example, women who have gone through menopause) should take all necessary measures such as calcium and vitamin D supplements although no additional measures are needed because of PPI use. PPIs may also increase the risk of certain intestinal infections including C. difficile. Again, the level of risk is small 5. As with all medicines, PPIs should be taken in the lowest effective dose. Both PPIs and H2RAs have been associated with some interactions with other medicines. Therefore, it is always important to discuss use of these drugs with a doctor. Most of the interactions with H2RAs, PPIs and other drugs are not serious. However, it is likely that at least some PPIs may reduce the effectiveness of clopidogrel, which is a medicine that reduces blood clotting activity and is used for people with certain heart or blood vessel problems. People taking clopidogrel should probably avoid certain PPIs and should certainly discuss this with their physicians. Prokinetic drugs are used in some countries as part of the treatment of heartburn. They are used in an attempt to limit the amount of stomach acid getting into the esophagus and / or to move any acid in the esophagus back into the stomach. Currently available prokinetic drugs are not particularly reliable or effective. They are only used in some countries and generally only by prescription. World Digestive Health Day WDHD May 29, 2015 WGO HANDBOOK HEARTBURN: A GLOBAL PERSPECTIVE 15
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