Gastroesophageal reflux disease medical therapy: Difference between revisions

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Latest revision as of 21:50, 29 July 2020

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ahmed Elsaiey, MBBCH [2]

Overview

The mainstay treatment of GERD is lifestyle modifications which include weight loss, elevating head of the bed and no eating before going sleep. The pharmacologic medical therapy is recommended among patients with persistent GERD despite following the lifestyle modifications. Antacids, histamine receptor antagonists, proton pump inhibitors, and prokinetics medications are used in treatment of GERD.

Medical Therapy

Lifestyle Modifications

The following measures are recommended as the first line to treat GERD:^[1]^[2]^[3]^[4]
- Weight loss
- Elevating head of the bed
- No eating two hours before going sleep
Avoidance of the following foods and lifestyles is recommended in treatment of GERD:
- Coffee
- Alcohol
- Excessive amounts of Vitamin C supplements
- Foods high in fats
- Smoking
- Eating shortly before bedtime
- Large meals
- Chocolate and peppermint.
- Acidic foods, such as oranges and tomatoes.
- Cruciferous vegetables such as: Onions, cabbage, cauliflower, broccoli, spinach, brussel sprouts
- Milk and milk-based products

Medical therapy

The medical therapy is indicated for the patients who have persistent GERD regardless the lifystyle and food modifications.^[5]^[6]
The following medical therapies are strongly recommended by the American College of Gastroenterology:
- Antacids:
  - Preferred regimen (1): Aluminum hydroxide 640 mg 5 to 6 times daily PO after meals and at bed time.
  - Preferred regimen (2): Calcium carbonate One gram PO.
- Histamine-receptor antagonists (H2RA):
  - Preferred regimen (1): Ranitidine 150 mg q12 daily PO
  - Preferred regimen (2): Cimetidine 400 mg q6h or 800 mg q12 PO for 12 weeks
  - Preferred regimen (3): Famotidine 20 mg q12 PO for 6 weeks
- Proton pump inhibitors:
  - Preferred regimen (1): Omeprazole 20 mg q24 PO for up to 4 weeks
  - Preferred regimen (2): Esomeprazole 20 mg or 40 mg q24 IV
- Prokinetic medications:
  - Preferred regimen (1): Metoclopramide 10 mg q24 PO for 4 to 12 weeks

References

↑ Piesman M, Hwang I, Maydonovitch C, Wong RK (2007). "Nocturnal reflux episodes following the administration of a standardized meal. Does timing matter?". Am. J. Gastroenterol. 102 (10): 2128–34. doi:10.1111/j.1572-0241.2007.01348.x. PMID 17573791.
↑ Kaltenbach T, Crockett S, Gerson LB (2006). "Are lifestyle measures effective in patients with gastroesophageal reflux disease? An evidence-based approach". Arch. Intern. Med. 166 (9): 965–71. doi:10.1001/archinte.166.9.965. PMID 16682569.
↑ Ness-Jensen E, Hveem K, El-Serag H, Lagergren J (2016). "Lifestyle Intervention in Gastroesophageal Reflux Disease". Clin Gastroenterol Hepatol. 14 (2): 175-82.e1-3. doi:10.1016/j.cgh.2015.04.176. PMC 4636482. PMID 25956834.
↑ Khoury RM, Camacho-Lobato L, Katz PO, Mohiuddin MA, Castell DO. Influence of spontaneous sleep positions on nighttime recumbent reflux in patients with gastroesophageal reflux disease. Am J Gastroenterol 1999;94:2069-73. PMID 10445529.
↑ Tran T, Lowry A, El-Serag H (2007). "Meta-analysis: the efficacy of over-the-counter gastro-oesophageal reflux disease drugs". Aliment Pharmacol Ther. 25 (2): 143–53. doi:10.1111/j.1365-2036.2006.03135.x. PMID 17229239.
↑ Decktor DL, Robinson M, Maton PN, Lanza FL, Gottlieb S. Effects of Aluminum/Magnesium Hydroxide and Calcium Carbonate on Esophageal and Gastric pH in Subjects with Heartburn. Am J Ther 1995;2:546-552. PMID 11854825.

Template:WH Template:WS

[pmid17573791-1] Piesman M, Hwang I, Maydonovitch C, Wong RK (2007). "Nocturnal reflux episodes following the administration of a standardized meal. Does timing matter?". Am. J. Gastroenterol. 102 (10): 2128–34. doi:10.1111/j.1572-0241.2007.01348.x. PMID 17573791.

[pmid16682569-2] Kaltenbach T, Crockett S, Gerson LB (2006). "Are lifestyle measures effective in patients with gastroesophageal reflux disease? An evidence-based approach". Arch. Intern. Med. 166 (9): 965–71. doi:10.1001/archinte.166.9.965. PMID 16682569.

[pmid259568342-3] Ness-Jensen E, Hveem K, El-Serag H, Lagergren J (2016). "Lifestyle Intervention in Gastroesophageal Reflux Disease". Clin Gastroenterol Hepatol. 14 (2): 175-82.e1-3. doi:10.1016/j.cgh.2015.04.176. PMC 4636482. PMID 25956834.

[4] Khoury RM, Camacho-Lobato L, Katz PO, Mohiuddin MA, Castell DO. Influence of spontaneous sleep positions on nighttime recumbent reflux in patients with gastroesophageal reflux disease. Am J Gastroenterol 1999;94:2069-73. PMID 10445529.

[pmid17229239-5] Tran T, Lowry A, El-Serag H (2007). "Meta-analysis: the efficacy of over-the-counter gastro-oesophageal reflux disease drugs". Aliment Pharmacol Ther. 25 (2): 143–53. doi:10.1111/j.1365-2036.2006.03135.x. PMID 17229239.

[6] Decktor DL, Robinson M, Maton PN, Lanza FL, Gottlieb S. Effects of Aluminum/Magnesium Hydroxide and Calcium Carbonate on Esophageal and Gastric pH in Subjects with Heartburn. Am J Ther 1995;2:546-552. PMID 11854825.

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[6]

@@ Line 1: / Line 1: @@
 __NOTOC__
 {{Gastroesophageal reflux disease}}
-{{CMG}} {{AE}}
+{{CMG}}; {{AE}} {{AEL}}
 ==Overview==
+The mainstay treatment of GERD is lifestyle modifications which include [[weight loss]], elevating head of the bed and no eating before going sleep. The pharmacologic medical therapy is recommended among patients with persistent GERD despite following the lifestyle modifications. [[Antacids]], [[H2 antagonist|histamine receptor antagonists]], [[proton pump inhibitors]], and [[Prokinetic|prokinetics medications]] are used in treatment of GERD.
 ==Medical Therapy==
 ===Lifestyle Modifications===
-The following measures are recommended as the first line to treat GERD:<ref name="pmid17573791">{{cite journal |author=Piesman M, Hwang I, Maydonovitch C, Wong RK |title=Nocturnal reflux episodes following the administration of a standardized meal. Does timing matter? |journal=Am. J. Gastroenterol. |volume=102 |issue=10 |pages=2128–34 |year=2007 |pmid=17573791 |doi=10.1111/j.1572-0241.2007.01348.x}}</ref><ref name="pmid16682569">{{cite journal |author=Kaltenbach T, Crockett S, Gerson LB |title=Are lifestyle measures effective in patients with gastroesophageal reflux disease? An evidence-based approach |journal=Arch. Intern. Med. |volume=166 |issue=9 |pages=965–71 |year=2006 |pmid=16682569 |doi=10.1001/archinte.166.9.965}}</ref><ref name="pmid259568342">{{cite journal| author=Ness-Jensen E, Hveem K, El-Serag H, Lagergren J| title=Lifestyle Intervention in Gastroesophageal Reflux Disease. | journal=Clin Gastroenterol Hepatol | year= 2016 | volume= 14 | issue= 2 | pages= 175-82.e1-3 | pmid=25956834 | doi=10.1016/j.cgh.2015.04.176 | pmc=4636482 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25956834  }}</ref>
+* The following measures are recommended as the first line to treat GERD:<ref name="pmid17573791">{{cite journal |author=Piesman M, Hwang I, Maydonovitch C, Wong RK |title=Nocturnal reflux episodes following the administration of a standardized meal. Does timing matter? |journal=Am. J. Gastroenterol. |volume=102 |issue=10 |pages=2128–34 |year=2007 |pmid=17573791 |doi=10.1111/j.1572-0241.2007.01348.x}}</ref><ref name="pmid16682569">{{cite journal |author=Kaltenbach T, Crockett S, Gerson LB |title=Are lifestyle measures effective in patients with gastroesophageal reflux disease? An evidence-based approach |journal=Arch. Intern. Med. |volume=166 |issue=9 |pages=965–71 |year=2006 |pmid=16682569 |doi=10.1001/archinte.166.9.965}}</ref><ref name="pmid259568342">{{cite journal| author=Ness-Jensen E, Hveem K, El-Serag H, Lagergren J| title=Lifestyle Intervention in Gastroesophageal Reflux Disease. | journal=Clin Gastroenterol Hepatol | year= 2016 | volume= 14 | issue= 2 | pages= 175-82.e1-3 | pmid=25956834 | doi=10.1016/j.cgh.2015.04.176 | pmc=4636482 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25956834  }}</ref><ref>Khoury RM, Camacho-Lobato L, Katz PO, Mohiuddin MA, Castell DO. Influence of spontaneous sleep positions on nighttime recumbent reflux in patients with gastroesophageal reflux disease. ''Am J Gastroenterol'' 1999;94:2069-73. PMID 10445529.</ref>
-* Weight loss
+** [[Weight loss]]
-* Elevating head of the bed
+** Elevating head of the bed
-* No eating two hours before going sleep
+** No eating two hours before going sleep
+* Avoidance of the following foods and lifestyles is recommended in treatment of GERD:
+**[[Coffee]]
+**[[Alcohol]]
+**Excessive amounts of [[Vitamin C]] supplements
+**Foods high in fats
+**[[tobacco smoking|Smoking]]
+**Eating shortly before bedtime
+**Large meals
+**[[Chocolate]] and [[peppermint]].
+**[[Acid]]ic foods, such as oranges and tomatoes.
+**[[Cruciferous vegetables]] such as: Onions, cabbage, cauliflower, broccoli, spinach, brussel sprouts
+**[[Milk]] and milk-based products
-===Foods===
+=== Medical therapy ===
-Certain foods and lifestyle are considered to promote gastroesophageal reflux:
+* The medical therapy is indicated for the patients who have persistent GERD regardless the lifystyle and food modifications.<ref name="pmid17229239">{{cite journal |author=Tran T, Lowry A, El-Serag H |title=Meta-analysis: the efficacy of over-the-counter gastro-oesophageal reflux disease drugs |journal=Aliment Pharmacol Ther |volume=25 |issue=2 |pages=143-53 |year=2007 |id=PMID 17229239 | doi=10.1111/j.1365-2036.2006.03135.x}}</ref><ref>Decktor DL, Robinson M, Maton PN, Lanza FL, Gottlieb S. Effects of Aluminum/Magnesium Hydroxide and Calcium Carbonate on Esophageal and Gastric pH in Subjects with Heartburn. ''Am J Ther'' 1995;2:546-552. PMID 11854825.</ref>
-*[[Coffee]], [[alcoholic beverage|alcohol]], and excessive amounts of [[Vitamin C]] supplements stimulate gastric acid secretion. Taking these before bedtime especially can cause evening reflux. (Although a study published in 2006 by Stanford University researchers disputes the effect of coffee, acidic, spicy foods etc. as a myth.<ref name="pmid16682569" />)
+* The following medical therapies are strongly recommended by the American College of Gastroenterology:
-*[[Antacids]] based on [[calcium carbonate]] (but not [[aluminum hydroxide]]) were found to actually increase the acidity of the stomach. However, all antacids reduced acidity in the lower esophagus, so the net effect on GERD symptoms may still be positive.<ref>Decktor DL, Robinson M, Maton PN, Lanza FL, Gottlieb S. Effects of Aluminum/Magnesium Hydroxide and Calcium Carbonate on Esophageal and Gastric pH in Subjects with Heartburn. ''Am J Ther'' 1995;2:546-552. PMID 11854825.</ref>.
+** '''[[Antacids]]''':
-*Foods high in fats and [[tobacco smoking|smoking]] reduce lower esophageal sphincter competence, so avoiding these tends to help. Fat also delays stomach emptying.
+*** Preferred regimen (1): [[Aluminum hydroxide]] 640 mg 5 to 6 times daily PO after meals and at bed time.
-*Eating shortly before bedtime (For clinical purposes, this usually means 2-3 hours before going to bed).
+*** Preferred regimen (2): [[Calcium carbonate]] One gram PO.
-*Large meals.  Having more but smaller meals reduces GERD risk, as it means there is less food in the stomach at any one time.
+** '''Histamine-receptor antagonists (H2RA):'''
-*Soda or pop (regular or diet).
+*** Preferred regimen (1): [[Ranitidine]] 150 mg q12 daily PO
-*[[Chocolate]] and [[peppermint]].
+*** Preferred regimen (2): [[Cimetidine]] 400 mg q6h or 800 mg q12 PO for 12 weeks
-*[[Acid]]ic foods, such as oranges and tomatoes.
+*** Preferred regimen (3): [[Famotidine]] 20 mg q12 PO for 6 weeks
-*[[Cruciferous vegetables]]: onions, cabbage, cauliflower, broccoli, spinach, brussel sprouts.
+** '''[[Proton pump inhibitors]]:'''
-*[[Milk]] and milk-based products contain calcium and fat, and should be avoided before bedtime.
+*** Preferred regimen (1): [[Omeprazole]] 20 mg q24 PO for up to 4 weeks
+*** Preferred regimen (2): [[Esomeprazole]] 20 mg or 40 mg q24 IV
-===Positional therapy===
+** '''[[Prokinetic|Prokinetic medications]]:'''
-Sleeping on one's left side has been shown to drastically reduce night time reflux episodes in patients.<ref>Khoury RM, Camacho-Lobato L, Katz PO, Mohiuddin MA, Castell DO. Influence of spontaneous sleep positions on nighttime recumbent reflux in patients with gastroesophageal reflux disease. ''Am J Gastroenterol'' 1999;94:2069-73. PMID 10445529.</ref>.
+*** Preferred regimen (1): [[Metoclopramide]] 10 mg q24 PO for 4 to 12 weeks
-Elevating the head of the bed is also effective. When combining drug therapy, food avoidance before bedtime, and elevation of the head of the bed, over 95% of patients will have complete relief. Additional conservative measures may be considered if there is incomplete relief. Another approach is to apply all conservative measures for maximum response. A [[meta-analysis]] suggested that elevating the head of bed is an effective therapy, although this conclusion was only supported by nonrandomized studies <ref name="pmid16682569" />.
-Elevating the head of the bed can be done by using various items: plastic or wooden bed risers that support bed posts or legs, a bed wedge pillow, or a wedge or an inflatable mattress lifter that fits in between mattress and box spring. The height of the elevation is critical and must be at least 6 to 8&nbsp;inches (15 to 20&nbsp;cm) in order to be at least minimally effective to prevent the backflow of gastric fluids. It should be noted that some innerspring mattresses do not work well when inclined and tend to cause back pain, thus foam based mattresses or futons are to be preferred. Some report relief from back pain by sleeping with one leg  bent at the knee, alternating legs. Moreover, some use higher degrees of incline than provided by the commonly suggested 6 to 8&nbsp;inches (15 to 20&nbsp;cm) and claim greater success.
-===Drug treatment===
-A number of drugs are registered for GERD treatment, and they are among the most-often-prescribed forms of [[medication]] in most Western countries. They can be used in combination with other drugs, although some antacids can interfere with the function of other drugs:
-*[[Proton pump inhibitor]]s are the most effective in reducing gastric acid secretion.  These drugs stop acid secretion at the source of acid production, i.e., the proton pump.
-*[[Antacid]]s before meals or symptomatically after symptoms begin can reduce gastric acidity (increase [[pH]]).
-*[[Alginic acid]] ([[Gaviscon]]) may coat the mucosa as well as increase pH and decrease reflux. A [[meta-analysis]] of [[randomized controlled trials]] suggests [[alginic acid]] may be the most effective of non-prescription treatments with a [[number needed to treat]] of 4 <ref name="pmid17229239">{{cite journal |author=Tran T, Lowry A, El-Serag H |title=Meta-analysis: the efficacy of over-the-counter gastro-oesophageal reflux disease drugs |journal=Aliment Pharmacol Ther |volume=25 |issue=2 |pages=143-53 |year=2007 |id=PMID 17229239 | doi=10.1111/j.1365-2036.2006.03135.x}}</ref>.
-*Gastric [[H2 antagonist|H<sub>2</sub> receptor blockers]] such as [[ranitidine]] or [[famotidine]] can reduce gastric secretion of acid. These drugs are technically [[antihistamine]]s. They relieve complaints in about 50% of all GERD patients. Compared to placebo (which also is associated with symptom improvement), they have a [[number needed to treat]] of eight (8) <ref name="pmid17229239">.</ref>.
-*[[Prokinetic]]s strengthen the LES and speed up gastric emptying. [[Cisapride]], a member of this class, was withdrawn from the market for causing [[Long QT syndrome]].
-*[[Sucralfate]] (Carafate®) is also useful as an adjunct in helping to heal and prevent esophageal damage caused by GERD, however it must be taken several times daily and at least two (2) hours apart from meals and medications.
 ==References==
@@ Line 47: / Line 48: @@
 [[Category:Gastroenterology]]
-[[Category:Primary care]]