International GERD Awareness Week
Gastroesophageal Reflux Disease (GERD)
November 23st through November 29th has been designated International GERD Awareness Week for 2015. An estimated 25 million adults experience heartburn daily, and over 38 million annual outpatient visits are related to this disease.1 You may have heard of GERD, or Gastroesophageal Reflux Disease, most likely in association with heartburn, but what is it exactly? The most common definition of GERD identifies it as the symptoms and damage associated with chronic and recurring abnormal backward flow (reflux) of the contents of the stomach into the esophagus. The burning sensation that the reflux can sometimes cause is what is typically referred to as heartburn. While usually not life-threatening, GERD has a significantly negative impact on the quality of life of those living with this condition. In addition, complications of GERD range from erosion of the cells in the esophageal lining to adenocarcinoma (a type of cancer).
What causes GERD?
Between the esophagus and stomach lies a sphincter, or valve, that opens in order for food to pass into the stomach.2 Improper function of this valve allows for the reflux to occur, and can happen for 3 different reasons: (1) the sphincter relaxes at the wrong time, (2) the sphincter weakens, or (3) the pressure in the abdomen is increased. While the cells lining the stomach are protected against its strong acidity, the cells lining the esophagus are not. When frequently exposed to the stomach contents, these cells can become inflamed and even erode in some instances.
Who has GERD?
The disease can occur at any age, but is commonly seen in those over 40. 2 In general, there is no significant difference in its prevalence between men and women, although pregnant women frequently experience GERD due to hormonal changes and increase in abdominal pressure. Those with asthma, diabetes, peptic ulcers, or obesity are also more likely to have GERD. 3 However, the prevalence of the disease is hard to assess for 2 reasons, the first being that there is no gold standard in diagnosing the disease, and second, many patients do not seek medical treatment for their symptoms.1,2
The lack of set criteria for diagnosing the disease makes it hard to characterize and distinguish from other problems such as ulcers and cancer. 4 Therefore, many factors are considered before a diagnosis of GERD is made, including patient family history, an endoscopy to check the lining of the esophagus, or a short trial of certain medications called proton-pump inhibitors (PPIs).
What are the symptoms of GERD?
Like previously stated, heartburn is the most commonly experienced symptom, however others include sore throat, hoarseness, chronic cough, asthma, chest pain, and a sensation of a lump in the throat. It should be noted that while occasional heartburn is fairly common in a healthy population, those with GERD experience it on a much more frequent basis.
Foods and medications can worsen GERD symptoms
Certain foods and drugs can worsen the symptoms of GERD either by lowering the esophageal sphincter pressure, making it easier to open, or by directly irritating the lining of the esophagus. A list of these foods and medications can be found in Tables 1 and 2, respectively.
Table 1: Foods that Worsen GERD Symptoms2,4
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Decrease Lower Esophageal Sphincter Pressure
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· Onions
· Garlic
· Chili Peppers
· Fatty Meals
· Carminatives – Peppermint, spearmint
· Chocolate
· Coffee, colas, tea
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Direct Irritants to Esophageal Lining
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· Spicy Foods
· Tomato Juice
· Coffee
· Orange Juice
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Table 2: Medications that CanWorsen GERD Symptoms2
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Decrease Lower Esophageal Sphincter Pressure
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· Ethanol
· Nicotine
· Caffeine
· Anticholinergics – group of medications that can affect the transmission of nerve impulses to the gastrointestinal tract, urinary tract, lungs, etc
· Nitrates – used to treat angina
· Dihydropyridine calcium channel blockers – used to treat high blood pressure
· Tetracycline – an antibiotic
· Theophylline – used to treat asthma and other lung disease
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Direct Irritants to Esophageal Lining
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· Iron
· Potassium
· Alendronate – for the treatment and prevention of osteoporosis
· Nonsteroidal anti-inflammatory drugs – pain medications such as ibuprofen, aspirin,
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How is GERD treated?
It is essential to talk to your physician before starting any therapy for GERD, to find out if you are a candidate for self treatment or if you should be under their supervision.4,5 Certain symptoms such as hoarseness, coughing, weight loss, vomiting, and chest pain are some of the more alarming ones that would warrant physician assisted care. Also, conditions like pregnancy and age younger than 16 or older than 50, should be under a provider’s care when initiating any medications.
Goals of therapy1
The goals for the treatment of GERD are to:
The goals for the treatment of GERD are to:
· Alleviate or eliminate symptoms
· Decrease the frequency, recurrence, and duration of GERD
· Heal any injured esophageal lining
· Prevent complications
Lifestyle Modifications 2,3,4
This is usually the first approach to treatment of symptoms of GERD. Some lifestyle modifications include:
· Elevating the head while sleeping
· Dietary changes
o Avoiding foods that can aggravate condition
o Eating protein rich meals (this helps with esophageal sphincter pressure)
o Eating small meals
o Avoid eating 3 hours prior to sleep
· Reduction in weight
· Smoking cessation
· Avoiding alcohol
· Avoiding tight fitting clothes
· If possible, discontinuing drugs that aggravate symptoms (always double check with your physician first).
Medications 1,2,4
Over-the-counter and prescription drugs are available to help treat the symptoms of GERD. The most basic medications are antacids, which work by lowering the acidity of the gastric juices; they are fast acting and fairly harmless. Histamine type-2 receptor agonists (H2 antagonist) drugs are relatively effective in alleviating heartburn, and work by decreasing gastric acid production; all are available over the counter. PPI drugs work to reduce gastric acid production over a long period of time and have been found to be somewhat more effective than H2 antagonists in treating heartburn. A list of drugs can be found in Table 3.
Over-the-counter and prescription drugs are available to help treat the symptoms of GERD. The most basic medications are antacids, which work by lowering the acidity of the gastric juices; they are fast acting and fairly harmless. Histamine type-2 receptor agonists (H2 antagonist) drugs are relatively effective in alleviating heartburn, and work by decreasing gastric acid production; all are available over the counter. PPI drugs work to reduce gastric acid production over a long period of time and have been found to be somewhat more effective than H2 antagonists in treating heartburn. A list of drugs can be found in Table 3.
Table 3: Medications Used to Treat GERD1,4,6,7
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Drug Class
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Drug Name (generic name)
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Common Side Effects
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Patient Informationa
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Antacids
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Tums, Rolaids, Gaviscon (Calcium Carbonate)
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∙ Stomach upset
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∙ Can be used as needed
∙ Have fast onset of action
∙ Should be separated from certain medications by 2 to 4 hours to avoid drug interactions. Discuss with your pharmacist for more information.
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H2 Antagonists
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Zantac (ranitidine)
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∙ headache
∙ constipation
∙ diarrhea
∙ nausea
∙ vomiting
∙ stomach pain
∙ dizziness
∙ rash
∙ breast enlargementc
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∙ Patients should contact their prescriber if symptoms persist and they have to use these medications for more than 14 days.
∙ Talk to your doctor if pregnant or breastfeeding.
∙ It is advisable to take these medications a half hour to one hour before a meal.
∙ If planning on taking cimetidine, patients should talk to their prescribers if already on theophylline, warfarin, and phenytoin (these medications interact with cimetidine).
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Pepcid (famotidine)
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Tagamet (cimetidine)b
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Axid (nizatidine)
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Proton-Pump Inhibitors
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Prilosec (omeprazole)
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∙ stomach pain
∙ diarrhea
∙ headache
∙ nausea
∙ constipation
∙ bloating
∙ flatulence
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∙ Take half hour to an hour before a meal.
∙ Contact your doctor if you experience any of the side effects.
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Nexium (esomeprazole)
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Protonix (pantoprazole)
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Aciphex (rabeprazole)
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Prevacid (lansoprazole)
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Dexilant
(dexlansoprazole)
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a Before starting any medication, be sure to check with your doctor or pharmacist about whether any of them interact with medications you are currently taking; b Caution should be taken when using cimetidine because of its susceptibility to numerous drug interactions; c Breast enlargement could be experienced with cimetidine.
If lifestyle changes and medication fail to alleviate symptoms of GERD, a final option is surgery.1 Several different procedures can be done, but all focus on strengthening the sphincter and reducing reflux.
Conclusion
GERD is a chronic disease that can severely impact the quality of life for those who suffer from it; severe cases can even develop into cancer. However, implementation of lifestyle modifications, along with different medications can help improve and manage this condition. When treatments fail to work, another viable option is surgery.
For more information on GERD visit these resources:
- American Gastroenterological Association:
http://www.gastro.org/patient-center/digestive-conditions/heartburn-gerd
- UC San Diego Health System:
http://health.ucsd.edu/specialties/esophageal-center/GERD.htm
- The Mayo Clinic:
http://www.mayoclinic.com/health/gerd/DS00967
- International Foundation for Functional Gastrointestinal Disorders:
1-888-964-2001
Asha Kalichira, PharmD Student 2014
Milena Babic, PharmD Candidate 2011
References:
1. University of Michigan Health System, Ann Arbor, MI. Gastroesophageal Reflux Disease. http://cme.med.umich.edu/pdf/guideline/GERD07.pdf. Updated January 2007. Accessed October 27, 2010.
2. Williams DB, Schade RR. Gastroesophogeal reflux disease. In: DiPiro JT, Talbert RL, Yee G, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach. 7th ed. New York, NY: McGraw-Hill; 2008: 555-567.
3. UC San Diego Health System. Gastroesophageal Reflux (GERD). http://health.ucsd.edu/specialties/esophageal-center/GERD.htm. Accessed October 27, 2010.
4. Kahrilas PJ, Shaheen NJ, Vaezi MF. American Gastroenterological Association medical position statement on the management of gastroesophageal reflux disease. Gastroenterology. 2008;135(4):1383-1391.
5. Henderson RP, Prince VT. Heartburn and dyspepsia. In: Berardi RR, McDermott JH, Newton GD, Oszko MA, Popovich NG, Rollins CJ, Shimp LA, Tietze KJ, eds. Handbook of Nonprescription Drugs. 14th ed. Washington, DC: American Pharmacist Association; 2004: 317-348.
6. Micromedex® Healthcare Series [Internet database]. Greenwood Village, CO: Thomson Reuters (Healthcare) Inc. Updated periodically.
7. Kastrup EK,ed. Drug Facts and Comparisons. St. Louis: MO; Wolters Kluwer Health; 2010.
