GERD: Its Burning Desire for Treatment

In gastroesophageal reflux disease (GERD), the reflux of stomach contents results in disruptive symptoms or complications.¹ GERD affects 10% to 20% of adults in western countries on a weekly basis and has the lowest prevalence in Asian countries.² A systematic review of 19 studies suggested that GERD results in an increase in time off work, a decrease in work productivity, a decrease in physical functioning, a decrease in sleep quality, and a decrease in overall quality of life.³ If left untreated, GERD can lead to esophagitis, Barrett’s esophagus, strictures, and esophageal adenocarcinoma.^1,3

PATHOPHYSIOLOGY

GERD has been primarily associated with a defective lower esophageal sphincter (LES), which allows stomach acid to reflux into the esophagus. This defection has been purported to be due to spontaneous transient LES relaxations, increases in intra-abdominal pressure, or an atonic LES. Other possible causes of GERD include abnormal esophageal anatomy; improper esophageal clearance of gastric fluids; reduced mucosal resistance to acid; delayed or ineffective gastric emptying; reduced salivary buffering of acid; or excessive gastric acid, pepsin, bile acids, and/or pepsin enzymes.^1,4

SIGNS AND SYMPTOMS

A diagnosis of GERD is generally made based on the combination of symptom presentation, objective testing with endoscopy, and response to medication therapy. However, it is generally accepted for patients to be given a diagnosis solely based on the typical symptoms. Table 1^1,4,5 lists the general symptoms and the symptoms that warrant further evaluation due to the possibility of a negative complication.^1,4,5

MANAGEMENT

The goals of treatment are to alleviate or eliminate GERD-related symptoms, decrease the recurrence and duration of GERD, and prevent the development of complications.^1,4,5 In 2013, the American College of Gastroenterology published guidelines regarding the management of GERD.⁴

Dietary and lifestyle interventions are recommended to complement pharmacotherapeutic interventions. Lifestyle interventions, such as weight loss, head-of-bed elevation, and avoidance of meals 2 to 3 hours before bedtime, have been shown to improve GERD symptoms, esophageal pH, and nocturnal gastric acidity. Although anecdotal evidence suggests a poorer prognosis in patients who consume tobacco, alcohol, chocolate, caffeine, spicy foods, and citrus carbonated beverages, the guidelines state that patients can continue to consume these foods and drinks because clinical evidence against their use is lacking. However, if patients experience GERD symptoms after consuming such foods or drinks, they may consider removing them from their diet.^1,4,5

Proton-pump inhibitors (PPIs) remain the key intervention for symptom management and erosive esophagitis management due to their ability to decrease gastric acid secretion. All PPIs are considered equivalent to one another; therefore, patients can switch products if they experience adverse effects or fail to respond to an initial PPI regimen.^1,4,5

The guidelines recommend an initial 8-week course of PPI therapy administered 30 to 60 minutes before the first meal (ie, once daily). The dosages for the agents are listed in Table 2. Maintenance therapy (ie, after the initial 8 weeks of therapy) is recommended for patients who still have symptoms after a PPI is originally discontinued or who have long-term complications (eg, erosive esophagitis, Barrett’s esophagus). In such cases, patients may need further evaluation, and may consider alternative therapeutic recommendations. For example, if patients need long-term PPI therapy, patients may be managed on on-demand or intermittent PPI therapy. Also, patients may receive bedtime H2RA therapy (ie, ranitidine or famotidine) for nighttime reflux or maintenance of breakthrough symptoms.⁴

PPIs have various potential risks that make clinicians wary of their use. PPIs have been historically associated with bone/hip fractures, infections, and hypomagnesemia.^1,4-6 In addition, recent data from cohort studies have linked long-term use of PPIs with dementia,⁷ chronic kidney disease,8 and myocardial infarction.⁹ Therefore, clinicians should continue to evaluate the use of PPI in all settings and use the lowest dose for the shortest duration possible when treating GERD, especially in patients with the conditions just listed.^1,4,5,10

Mohamed Jalloh, PharmD, is an instructor at Creighton University in Omaha, Nebraska, and a community pharmacist at Walgreens.

References

• May DB, Rao S. Gastroesophageal reflux disease. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L, eds. Pharmacotherapy: A Pathophysiologic Approach. 9th ed. New York, NY: McGraw-Hill; 2014.
• Dent J, El-Serag HB, Wallander MA, Johansson S. Epidemiology of gastro-oesophageal reflux disease: a systematic review. Gut. 2005;54(5):710-717.
• Becher A, El-Serag H. Systematic review: the association between symptomatic response to proton pump inhibitors and health-related quality of life in patients with gastro-oesophageal reflux disease. Aliment Pharmacol Ther. 2011;34(6):618-627. doi: 10.1111/j.1365-2036.2011.04774.x.
• Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol. 2013;108(3):308-328; quiz 329. doi: 10.1038/ajg.2012.444.
• Kahrilas P. Medical management of gastroesophageal reflux disease in adults. Wolters Kluwer UpToDate online database. uptodate.com/contents/medical-management-of-gastroesophageal-reflux-disease-in-adults?source=search_result&search=gerd&selectedTitle=2~150#H102013888. Accessed May 25, 2016.
• Clinical Pharmacology online database. clinicalpharmacology-ip.com/default.aspx. Accessed May 25, 2016.
• Haenisch B, von Holt K, Wiese B, et al. Risk of dementia in elderly patients with the use of proton pump inhibitors. Eur Arch Psychiatry Clin Neurosci. 2015;265(5):419-428. doi: 10.1007/s00406-014-0554-0.
• Lazarus B, Chen Y, Wilson FP, et al. Proton pump inhibitor use and the risk of chronic kidney disease. JAMA Intern Med. 2016;176(2):238-246. doi: 10.1001/jamainternmed.2015.7193.
• Shah NH, LePendu P, Bauer-Mehren A, et al. Proton pump inhibitor usage and the risk of myocardial infarction in the general population. PLoS One. 2015;10(6):e0124653. doi: 10.1371/journal.pone.0124653.
• Coggins MD. Recognizing proton pump inhibitor risks. Today’s Geriatric Medicine website. todaysgeriatricmedicine.com/archive/012014p6.shtml. Accessed May 25, 2016.