Initial Treatment Options for GERD
Treating early-stage GERD usually centers on a combination of lifestyle and dietary changes, over-the-counter (OTC) medications and prescription drug regimens. If the disease continues to worsen, to correct the root cause, the lower esophageal sphincter (LES) needs to be fixed using incisionless or conventional laparoscopic techniques.
Most people with reflux find that their symptoms are more serious at night. Gravity is not opposing the reflux when lying down, as it does in the upright position. Refluxed liquid travels farther up the esophagus and remains there longer.
It is recommended to elevate the upper body when lying in bed in order to decrease the amount and extent of reflux. Most people find that elevation with multiple pillows initially helps with their symptoms. However, as the reflux becomes more severe, they find that they must sleep upright in a chair to counteract the forces of their reflux.
Smoking is a significant contributor to reflux. Smoking reduces the pressure of the lower esophageal sphincter, thereby promoting reflux. Smoking also increases the chance of developing gastric and duodenal ulcers.
Several changes in eating habits can be beneficial in treating GERD. Reflux is worse following meals because the stomach is distended with food and transient relaxations of the lower esophageal sphincter are more frequent. Therefore, smaller, frequent meals and earlier evening meals may reduce the amount of reflux. Smaller meals result in decreased distention of the stomach and earlier meals allow the stomach to be empty by the time one is lying down to sleep.
Certain foods are known to reduce the pressure of the lower esophageal sphincter. These include:
- Caffeinated beverages
In addition, people find that the list of foods they cannot tolerate expands to include spicy, fatty, and acidic foods.
The First Steps
- Control alcohol and tobacco use
- Reduce trigger foods
- Adjust medications
- Become active (lose weight)
- Stay upright
- Adjust sleeping position (elevate upper body)
- Loosen clothing
Antacids such as Tums, Mylanta or Rolaids neutralize the acid in the stomach so that when the reflux occurs, there is less acid in the refluxate. Antacids work quickly but the problem is that their action is brief. They are emptied from the stomach in less than an hour and the acid then re-accumulates.
The best way to take antacids is to take them about one hour after eating a meal in order to stop symptoms before they begin.
H2 Blockers (Histamine Antagonists)
H2 blockers are medications such as Pepcid and Zantac. Histamine is a chemical that stimulates acid production by the stomach. When histamine attaches to receptors on the stomach’s acid producing cells, it signals the stomach to produce acid. H2 blockers work by binding and blocking these receptors on the stomach, thereby preventing histamine from stimulating the acid-producing cells.
H2 blockers work best when taken 30 minutes before meals so that they will peak in the body after the meal when the stomach is actively producing acid.
Proton Pump Inhibitors
Proton pump inhibitors block the secretion of acid into the stomach by the acid-secreting cells. They shut off acid producers (proton pumps) more completely and for a longer period of time than H2 blockers. PPI’s are not only good for treating symptoms, but are sometimes effective in protecting the esophagus from acid in order that esophageal inflammation (esophagitis) may heal.
Most Proton pump inhibitors (PPI’s) are prescription medications, but there are some over-the-counter formulations such as Prilosec OTC.
Examples of Proton pump inhibitors include: Nexium, Prevacid, Prilosec, Protonix, Aciphex, Zegerid, Kapidex, Dexilant and Vimovo.
PPI’s should be taken 30 to 60 minutes before a meal as they only bind to actively secreting proton pumps.
Pro-motility drugs are intended to empty the stomach earlier, which should reduce reflux. Multiple studies have been performed on pro-motility drugs. These studies have shown that this class of drugs is not very effective in treating either the symptoms or complications of GERD. The most common drugs in this class are Reglan (metoclopramide) and Urecholine (bethanecol).
Why Pharmaceuticals Are Not a Long-Term Solution
Medications are quite effective in treating mild to moderate GERD. The problem is that these medications lose their effectiveness over time. They also do not treat the underlying cause of reflux – the deteriorated anatomy of the anti-reflux barrier. Therefore, life-long medication therapy is required. In addition, recent studies are showing adverse effects with the long-term use of PPI’s. The FDA issued a warning regarding the increased incidence of hip, wrist and spine fractures in those taking PPI’s for longer than one year. Other associations have been found in various studies, such as increased risk of pneumonia, decreased Vitamin B12 absorption, increased gastric polyps, interference with anti-platelet medications such as Plavix and increased incidence of clostridium difficile colitis.
Here at The Reflux Center, we keep up to date on the latest information and can help you make an informed decision.
Gopal Grandhige, MD