Acid Reflux Treatment in Elderly Patients
Older patients often complain of less severe reflux symptoms than their younger cohorts, but because of prolonged acid exposure over years, the elderly may have more complicated disease. Treatment of the older patient with GERD follows the same principles as in other adults, although they may require more aggressive acid suppression therapy. Pill-induced esophagitis may complicate their treatment. Metoclopramide must be used with caution because of frequent side effects in the elderly. H 2RAs can be associated with mental changes in older patients, and doses need to be decreased in patients with renal insufficiency. Fewer drug interactions are seen with famotidine and nizatidine. Alternative methods of administering PPIs may be necessary in debilitated older patients who cannot swallow intact omeprazole or lansoprazole capsules. Both capsules can be opened and the granules taken with water, an HCO 3 --based suspension, or apple or orange juice, or the granules can be sprinkled on applesauce or yogurt.
Teratogenicity or fetal harm from absorption of medications across the placenta is the foremost consideration in the treatment of GERD during pregnancy. Lifestyle modifications and antacids or Gaviscon remain the cornerstones of treatment, providing adequate relief to the majority of women with mild symptoms. Although rarely used in adults, sucralfate is a nonabsorbable mucosal binder that has been found superior to lifestyle changes in a controlled study in pregnant women. Metoclopramide, H 2RAs, and most PPIs (except omeprazole) have a Category B FDA safety profile for use during pregnancy, based on animal studies showing no risk, as well as on small case series and anecdotal human reports. Ranitidine is the only one of these drugs shown to be effective during pregnancy. PPIs may be safe for aspiration prophylaxis before anesthesia for elective cesarean sections. Antacids, sucralfate, and most H 2RAs (except nizatidine) are safe to use during lactation, even though the latter group of drugs is excreted in breast milk. PPIs are not recommended during breast-feeding, based on safety concerns in animal studies.