TREATMENT OF GASTROESOPHAGEAL REFLUX DISEASE (GERD)
Most mildly symptomatic patients with reflux and some moderately afflicted individuals can be helped by simple measures designed to alter the frequency or type of esophageal reflux. Elevating the head of the bed by 6 to 8 inches is a simple and effective form of therapy. Esophageal pH monitoring has shown that this simple measure decreases the frequency and length of reflux episodes. Pillows to elevate the thorax do not work well, as patients tend to roll off the pillows during the night. A foam rubber wedge can be used if the bed frame cannot be moved. Avoiding food and fluid for at least 3 hours before retiring decreases the amount of material available for reflux at night. Avoiding food that the patient finds distressing and that may decrease LES pressure, such as fatty foods, chocolate, and onions, makes sense but has never been subjected to clinical trial. Acid can be neutralized by taking 30 mL of aluminum hydroxide-magnesium hydroxide antacid 1 and 3 hours after meals and at bedtime, but most patients do not tolerate frequent antacid administration. An attempt should be made to have the patient stop smoking, drinking alcohol, and overeating.
If these simple measures are not effective, systemic medical treatment is indicated. The H2 -receptor antagonists in the usual dosage range for duodenal ulcer and titrated to the individual patient improve heartburn better than placebo. An increased frequency of administration and/or higher dosage regimens--cimetidine, 800 mg; ranitidine, 300 mg; or famotidine, 40 mg (each twice per day)--are more effective for controlling symptoms and healing peptic esophagitis, which usually requires 12 weeks.
The proton-pump inhibitors omeprazole (20 mg/day) or lansoprazole (30 mg/day) can give dramatic symptom relief and heal esophagitis in 4 to 8 weeks. Proton-pump inhibitors are usually the treatment of choice for mucosal disease, especially moderate to severe esophagitis seen endoscopically.
Prokinetic agents may also be useful in the treatment of GERD symptoms with no to mild esophagitis, occasionally in addition to gastric acid suppressants. Metoclopramide, 10 mg given three times a day, can be helpful, but CNS side effects can occur in 25% of cases and may limit its usefulness.
Summary:
Step 1. Simple measures (lifestyle changes , dietary modifications and OTC antacids)
A. Elevate head of bed
B. Avoid food and fluid intake before bedtime
C. Avoid cigarettes, coffee, alcohol
D. Avoid chocolate, peppermint
E. Avoid tight clothing around the waist
F. Take antacids 1 hour after meals, at bedtime, and as needed
G. Reduce fat in diet
H. Lose weight
Step 2a.H2 -receptor antagonists
A. Cimetidine, 300 mg q.i.d.
B. Ranitidine, 150 mg b.i.d.
C. Famotidine, 20 mg b.i.d.
D. Nizatidine, 150 mg b.i.d.
Step 2b. Prokinetic agents
Metoclopramide, 10 mg q.i.d.
Step 3. Measures for patients with GERD resistant to H2 -receptor antagonists
Proton pump inhibitor: omeprazole, 20 mg/day, or lansoprazole, 30 mg/day
Step 4. Measures for patients with GERD resistant to steps 1, 2, and 3 or patients who need long-term maintenance treatment
Surgical fundoplication
Once healing of esophagitis has been achieved with either an H2 -antagonist or a proton-pump inhibitor, recurrence rates exceed 80% if no maintenance therapy is used. Maintenance therapy for esophagitis generally requires full dosage of an H2 -receptor antagonist or a proton-pump inhibitor.
Labels: acid reflux treatment