What is acid reflux?

The rationale for GERD therapy depends on a careful definition of specific aims. In patients without esophagitis, the therapeutic goals are simply to relieve the acid-related symptoms and to prevent frequent symptomatic relapses. In patients with esophagitis, the goals are to relieve symptoms and to heal the esophagitis while attempting to prevent further relapses and the development of complications. These goals are set against a complex background: GERD is a chronic disease that may wax and wane in intensity, and relapses are common.

Nonprescription Therapy
Although GERD is common in the United States, very few persons seek medical care for their complaints, instead choosing to change their lifestyles and self-medicate with over-the-counter (OTC) antacids and low doses of H 2RAs. These observations have led to the “iceberg” model of the GERD population. Most heartburn suffers are invisible because they self-medicate and do not seek professional help; only those at the tip of the iceberg, typically patients with severe symptoms or reflux complications, are seen by physicians.

Over-the-Counter Medications Over-the-counter antacids, Gaviscon, and H 2RAs are useful in treating mild and infrequent heartburn symptoms, especially when symptoms are brought on by lifestyle indiscretions. Antacids increase LES pressure but work primarily by buffering gastric acid in the esophagus and stomach, albeit for relative short periods. Heartburn symptoms are rapidly relieved, but patients need to take antacids frequently, usually 1 to 3 hours after meals and at bedtime, depending on symptom severity. Gaviscon, containing alginic acid and antacids, mixes with saliva to form a highly viscous solution that floats on the surface of the gastric pool and acts as a mechanical barrier. Both antacids and Gaviscon are more effective than placebo in relieving symptoms induced by a heartburn-promoting meal. However, these agents do not heal esophagitis, and long-term trials suggest effective symptom relief in only 20% of patients using antacids. Side effects of antacids and Gaviscon are minimal but include diarrhea from magnesium-containing antacids, constipation from aluminium-containing antacids, salt overload, magnesium or aluminium toxicity in patients with renal disease, and the milk-alkali syndrome (hypercalcemia, alkalosis, renal failure) from long-term and excessive use of calcium-containing antacids. H 2RAs are available in an OTC form at doses that are usually one half of the standard prescription dose. Although there are some differences in potency, duration, and rapidity of action, these drugs may be used interchangeably. Although their onset of relief is not as rapid as that of antacids, the OTC H 2RAs have a longer duration of action, up to 6 to 10 hours. Therefore, they are particularly useful when taken before a potentially refluxogenic activity, such as a heavy meal or exercise. Like antacids, the OTC H 2RAs are ineffective in healing esophagitis and should not be used regularly for more than 2 weeks.

Prescription Medication Therapy
Patients with frequent heartburn, esophagitis, or complications of GERD usually see a physician and receive prescription medications for their disease. Although prokinetic drugs attempt to correct the motility disorder associated with GERD, the most clinically effective medications for short- and long-term reflux treatment are the acid suppressive drugs.