Acid Reflux Disease

Natural Remedies For Acid Reflux - An Amazing Solution

2009-03-17T20:42:00.001-07:00

Acid reflux disease is also known as heartburn or GERD (gastro esophageal reflux disease) and it is caused by stomach acid refluxed back to esophagus from the stomach. The common symptoms of this disease include discomfort, burning sensation through esophagus after meal; difficulty is swallowing, throat pain and breathing problems. Natural remedies for acid reflux diseases are the promising solution for long painful discomfort caused by the disease. Actually there are some amazing natural remedies including herbs that are the best solution for eliminating acid reflux disease for rest of the life.

There are many medicines available over the counter as well as many medical professionals prescribe antacids as well as anti histamines for acid reflux, however antacids are basic in nature and reduce the affect of acids and antihistamines reduce acid formation in stomach. Both the medicines can cause severe damage to stomach if taken for a long period and therefore should be avoided for long periods.

There are numerous natural remedies that have been practices since thousands of years and are still being treated as the best proven solutions for eliminating the acid reflux permanently. One of the best habits to keep this disease at bay is to take the proper food. Fatty and spicy foods should be avoided as these can aggravate the problems. Certain citrus fruits are also responsible for enhancing stomach acid production and therefore these should also be removed from your daily diet. Some fruits including papaya, banana and apple can help in reducing the stomach acid formation and therefore should be included in the diet.

Apple cider vinegar is amongst the best natural remedies for its treatment and if diluted apple cider vinegar is taken half an hour before meal, it amazingly help in eliminating the acid reflux or GERD.

Acid Reflux – lifestyle Changes Can Help Cure GERD

2009-03-17T20:40:00.001-07:00

It is natural to get heartburn occasionally. It can be somehow unpleasant, but usually it's nothing to worry about. However, if you get it regularly, it might be caused by acid reflux disease.

Acid reflux is known as Gastroesophageal Reflux Disease, or GERD. It is a state of chronic abnormal reflux of stomach acid into the esophagus. It is caused by the dysfunction of the lower esophageal sphincter (LES). This sphincter is located at the opening of the stomach and it is a small ring of muscle. When it is not closed as tight as it should be, acid from the stomach will leak into the esophagus, causing this burning sensation. With time, it can corrode the lining of the esophagus causing ulcer and increasing the likelihood of esophageal cancer.

Watch out for the following symptoms because it means that you might have GERD:

-Persistent and frequent heartburn - This is the most obvious symptom, as well as the most common. Usually acid reflux sufferers experience heartburn several times a month. Oddly enough, some do not have heartburn at all.

-Acid Regurgitation - It is often reported that there is regurgitation of acid into the back of the throat, and sometimes all the way into the mouth for people with GERD. It might be accompanied by food from the stomach but not all the time.

-Persistent cough - Some sufferers develop a dry cough. When certain nerves in the lower esophagus are stimulated by the stomach acid it usually causes dry cough. But it can also be caused by acid irritating the throat.

-Choking sensation - It feels like a piece of food is stuck in the throat while in fact there is none.

-Croakiness or wheezing - When damage is done to the throat or esophagus, it will cause this sensation. It occurs usually in the morning. Besides, GERD can aggravate existing asthma.

Acid Reflux Treatment

You should definitely talk to your doctor if you have some of the symptoms above. If you are diagnosed with GERD, your doctor can prescribe some medications known as proton inhibitors. You can also try herbal remedies that can help in many cases. Surely enough, some lifestyle changes can provide relief without resorting to any medication. These include:

-Stop alcohol and tobacco consumption - They can make the symptoms of acid reflux worse. More acid is actually produced by the stomach when alcohol is consumed and the LES gets relaxed so more acid leaks. Smoking has the same effects; in addition, it causes saliva reduction, which provides a natural defense against refluxed acid.

-Weight loss is a must - Excess weight can make GERD worse because it increases pressure on the abdomen.

-Know what food to avoid - Stay away from fried and fatty foods, citrus fruits, tomatoes, chocolate, and spicy foods. Get into the habit of eating smaller meals to reduce abdominal pressure.

-Raise the head of your bed - When you're laying flat, acid escapes the stomach. That's why you might feel heartburn at night more than any other time. Sleeping slightly inclined can help. Also don't eat and sleep immediately.

It can be painful to have acid reflux but it can be cured with minor lifestyle changes and some medications.

Acid Reflux Treatment - Home Remedies Or Drugs?

2009-03-17T20:38:00.001-07:00

Let’s think, what is acid reflux? Which treatments are available? Are there any home remedies for acid treatment?

Acid reflux is basically a kind of digestive disorder. The most common symptom is heartburn or having difficulty in breathing. However, there are various of ways curing it. It is generally agreed that the fastest acid reflux treatment is by using drugs. These kinds of drugs are easily available in the market and like other drugs, it may bring certain risks or side effects to you such as allergies.

For those who would like to try alternative treatment, they may consider some of the more common home remedies which is usually easy to make without much difficulties. This normally involves changing life style such as your daily eating and drinking habit. By changing your lifestyle, it helps relieving your discomfort arose from acid reflux.

Creating home remedies for acid reflux is easy if you have the required ingredients. Things like cabbage, pineapples, papaya and vegetables are usually important elements that are used to make ginger root, apple cider vinegar and things like that. It should be reminded that these home remedies may only fix your problems temporary. If you are still facing acid reflux issues, then you are suggested to seek doctors' advice for long term treatment.

It is always advisable to seek acid reflux treatment as soon as the symptoms are found. The earlier you treat your diseases, the earlier you will recover from this kind of digestive disorder.

Symptoms of Acid Reflux Disease - The Top 7 Things That Could Answer Your Question

2009-03-17T20:37:00.001-07:00

If you are currently asking yourself the question - "Do I have acid reflux disease?" then it is time to investigate this painful and rather life changing condition to work out whether or not it is time to visit your doctor.

There are a few symptoms that are commonly associated with digestive diseases and conditions such as GERD and acid reflux disease and if you are noticing one of more of these symptoms, it is perhaps time to visit a medical professional that can better diagnose your symptoms. Home or self diagnosis will not get you the treatment that you will need so the only way to be safe and healthy is to visit your doctor.

Among the main symptoms of acid reflux disease, you may notice the following:

1. Heartburn. This is commonly described as a rather painful burning sensation within the chest area and can go as far down as the stomach and as far up as the neck

2. Pain in the chest, either constant or a nasty stabbing pain

3. Regurgitating food back from the gullet into the mouth

4. Trouble when swallowing both liquids and food

5. Sore throat and hoarseness when trying to talk

6. Erosion of the teeth and gums caused by the acid reaching the mouth

7. Asthma (This is normally due to the acid that is travelling where it should reaching the area around the lungs or throat)

These symptoms can happen all at once or in stages and all of them are very uncomfortable to have to deal with. They have the ability to seriously interfere with ones life and even lead to days taken from work as sick and not being able to leave the house due to the painful nature of the heartburn.

For those that have not suffered from heartburn, this can be one of the most painful things to ever have to go through and also one of the most difficult things to explain.

The symptoms of acid reflux disease can continue for many months and even longer, getting more and more painful as the time goes if it has not been treated in the correct manner.

Acid reflux Treatment can take the shape of many things from medication that your doctor may have prescribed for you to massive lifestyle changes that can make the difference between painful symptoms of acid reflux disease to bearable ones.

Fighting Acid Reflux With Prilosec

2009-03-17T20:33:00.001-07:00

Prilosec is the trademark brand name for omeprazole, an antacid drug that suppresses or decreases the amount of gastric acid secreted in the stomach. Prilosec is used for the treatment of gastroesophageal reflux disease (GERD), including duodenal and gastric ulcers.

By blocking an enzyme in the stomach wall that stimulates the secretion of gastric juices, Prilozec reduces the amount of such acid from being pulsed into the esophageal passage in a reflux reaction. It is generally thought that an overabundance of acid in the stomach will contribute to the acid reflux, as will obesity, pregnancy, or the wearing of tight fitting clothes. Therefore, a reduced quantity of acid sent up to the esophagus should cause less damage or irritation.

To fight acid reflux with Prilosec, look out for such symptoms as burning discomfort in the chest, difficulty in swallowing, and chronic chest pain. If you have heartburn more than once per week, you become more susceptible in contracting GERD; and so a course of treatment with Prilosec is advised. However, an occasional heartburn is not an uncommon thing and does not pose any risk of getting GERD.

Prilosec is not a prescription drug and so is readily available over the counter. Still, Prilosec is meant primarily for people who have frequent heartburns, such as getting it 2 to 3 times a week.

For Prilosec, one pill a day is enough to relieve heartburn for up to 24 hours, and this is part of a recommended 14-day course of therapy. This Prilosec treatment may be repeated once every 4 months if necessary, but not more than that. When undergoing a course of treatment, do not stop taking Prilosec even when you start to feel better.

Do not overdose on Prilosec. While it is generally true that high acidity in the stomach can lead to acid reflux, the opposite is ironically true as well. A lack of acid in the stomach can also prevent the stomach's exit valve to the small intestine from opening up. Instead, the contents in the stomach get to roll back up to the esophagus, and what little acid present may still cause irritation.

Your symptoms have improved and that's a good thing, but the condition still exists and so you need to carry through with the full length of treatment before this condition is considered as fully treated. If the heartburn condition does not improve or even worsen, you would need to consult with your doctor. However, this is not the only time you seek out your doctor.

As with all medicines, OTC or not, before taking Prilosec, always let your doctor know if you have any instance of painful swallowing, difficulty in swallowing, vomiting blood, and bloody or black stools.

Furthermore, if you have heartburn that has lasted three months or longer, or experience heartburn combined with wheezing, arm pain, jaw pain, neck pain, shoulder pain, chest pain, dizziness, lightheadedness, or sweating, make sure you let your doctor know before taking Prilosec.

Contact your physician if you experience frequent chest pains, inexplicable weight loss, vomiting, nausea, or stomach pain while taking the medication.

Acid Reflux - Food That You Can Eat

2009-03-17T20:31:00.001-07:00

Acid reflux, like any other dietary disease, has no simple and easy cure. Moderation is usually the best remedy for dietary diseases or disorders. Perhaps it would be good to shed some light on occurrence of acid reflux within the body. Acid reflux or heartburn in layman's terms happens when the stomach content in the body is too acidic and is subsequently sent back the reversed way to the esophagus.

The walls of the esophagus are designed to withstand neutral content and will cause pain and inflammation when acidic content is in contact with it. It can be liken to swallowing corrosive acid.

There is no hard and fast rule on what one should eat or not to avoid or cure acid reflux in the body. The occurrence of acid reflux tends to vary from person to person. For example, person A may feel experience acid reflux in the body after consuming read meat while person B may be fine with it. Before we start prescribing a rough remedy for ourselves, it would be best to understand the malady. Therefore, we should try our best to understand our body and what foods which cause it to happen in our bodies.

However, there are a few foods which are generally fine to be eaten to avoid acid reflux based on their content and low acidity levels. Fruits and vegetables are always a good bet for the body but no citrus fruits here as they are acidic.

Some good fruits are such as pineapple, banana and apples because they absorb acids whereas some good vegetables are such as cauliflower, broccoli and cabbage as they are alkaline in nature. These are acid reflux food to eat in order not to worsen your acid level.

Red meat is a big no but a healthy balance of meats, fish and grains is welcomed to improve digestion and avoid reverse flow of food content in the body. As a last example, please stay away from dairy products which triggers the stomach to release acids but low fat yogurt is fine.

Acid Reflux Sore Throat - 10 Simple Tips to Drive Away the Pain and Irritation

2009-03-17T20:30:00.001-07:00

Acid reflux sore throat is something that can be easily cured. It is caused when acid from the esophagus leaks and sits on your throat when you are asleep. Acid reflux sore throat irritation can be soothed by following a few simple tips. Here are 5 tips that can help you get rid of the problem in next to no time.

1. You should try and sleep with the upper half of your body at an elevated position. You can use a mattress or a pillow to get it elevated. Make sure that the entire upper half of the body is elevated and not the head portion alone. Sleeping in this position helps in keeping the acid inside the stomach and not enters the esophagus.

2. There are many amongst us who have the habit of sleeping with our mouth open. In such cases, air enters through the mouth and causes throat irritation. You can avoid this problem by installing a good humidifier at home, which can put moisture back into the air. This will not allow your throat to go dry.

3. Drinking lots of water also helps in getting rid of acid reflux sore throat pain and irritation. Although eight glasses will be enough, you can always drink more, if it is all right with you. Apart from helping you with your sore throat, it will also give you lots of other health benefits too.

4. Lozenges and cough drops are also known to give relief from acid reflux sore throat pain. They are to be used only when the pain is really bad and only in consultation with your doctor.

5. Gargling with salt water is a good way to start the day if you want to get rid of acid reflux sore throat pain. Soothing your throat with tea mixed with some honey is also known to give relief from throat irritation.

To be continued in the next post…

Home Remedies For Heartburn - Herbal Acid Reflux Treatment

2009-03-17T20:28:00.001-07:00

Evryday many people around the word complain about feeling something burning inside their chests. This is a very painful disorder known as heartburn. The intensity of the symptoms vary from one person to another and that's why some patients only feel a mild discomfort while others feel an unbelievable pain.

Everybody knows all the medical treatments for this condition but let's see how effective home remedies for heartburn are.

The common practice has proven home remedies to be very successful in time and now they've become a viable alternative to the prescribed medicine offering a risk free cure.

It's hard to estimate how many home remedies are available for heartburn but below you can read about a few of them that are considered to be best ones.

Let's start with ginger. Many sufferers said that after eating some ginger with their meal, the stomach upset was considerably reduced. You can use fresh ginger or capsule ginger because both have the same effect.

Also, any healthy diet must contain fiber because this cleans the digestive system keeping the stomach acids from returning to the esophagus.

Third in line are the digestive enzymes. This type of remedy speeds up the digestive process eliminating the heartburn. You can find them available in convenient chewy capsule form and you won't have to combine them with your meal or drink them with a glass of water.

The above mentioned herbal remedies for heartburn were very effective for most acid reflux sufferers but you should know that every single person is different. That's why the result cannot be the same for everybody. That's why you should try a few remedies and see which one offers the best results eliminating the pain from your chest.

Heartburn is a very unpleasant condition but if you're patient, you can forget about the symptoms very fast. I recommend you try these herbal acid reflux remedies but as always, make sure you consult your doctor first before proceeding.

Acid reflux disease - surgery has longterm success rate

2007-03-07T06:04:00.001-08:00

According to a Acid reflux disease study published this week in acid reflux magazines, surgery to cure acid reflux disease, the most severe form of heartburn, has shown a high degree of long-term success.

The surgery, a laparoscopic procedure, in which a small tube is inserted into the abdomen, was carried out on a group of 1,340 people, and 93 percent have declared they are satisfied with the long-term results.

Acid reflux disease occurs when stomach acid moves into the esophagus after a muscular valve designed to prevent such leakage opens up.

Laparoscopic surgery for acid reflux involves strengthening that natural barrier by wrapping part of the stomach around the lower part of the esophagus.

In the study which was conducted at University Hospital, Angers, France, the patients were followed on average for more than seven years after the surgery.

Although almost 10 percent of the patients resumed taking heartburn medicine, in most no evidence of reflux recurrence could be found.

The report concluded that the results suggest that laparoscopic anti-reflux surgery is an effective long-term procedure, is well tolerated, and can be properly used in the treatment of acid reflux disease.

Gastroesophageal Reflux Disease: Diagnosis and Management

2007-03-07T06:01:00.000-08:00

Gastroesophageal reflux disease (GERD) is a chronic, relapsing condition with associated morbidity and an adverse impact on quality of life. The disease is common, with an estimated lifetime prevalence of 25 to 35 percent in the U.S. population. GERD can usually be diagnosed based on the clinical presentation alone. In some patients, however, the diagnosis may require endoscopy and, rarely, ambulatory pH monitoring. Management includes lifestyle modifications and pharmacologic therapy; refractory disease requires surgery. The therapeutic goals are to control symptoms, heal esophagitis and maintain remission so that morbidity is decreased and quality of life is improved.
Gastroesophageal reflux is a normal physiologic event that may occur as often as once an hour.¹ The causes for the transformation of this normal process into a chronic, relapsing illness have not been well defined, but numerous factors are thought to be involved. The symptoms of gastroesophageal reflux disease (GERD) vary from patient to patient, and multiple diagnostic tests and treatments are available. Given the variability of symptoms and the prevalence of GERD, family physicians need to understand the presentations, diagnosis and treatments of this illness.

Overview of the Problem

As many as 10 percent of Americans have episodes of heartburn (pyrosis) every day, and 44 percent have symptoms at least once a month.^1,2 In all, GERD affects an estimated 25 to 35 percent of the U.S. population.³ Even though many persons with GERD may not seek medical care, annual health care costs related to this disease are still high.

Psychologic well-being questionnaires have found that patients with GERD can have a worse quality of life than some patients with menopausal symptoms, peptic ulcer disease, angina or congestive heart failure.⁴ The combination of symptoms, dietary restrictions and functional limitations can take a toll on overall sense of well-being.⁵

The natural course of GERD involves a decrease in symptoms despite the persistence of reflux. Three fourths of conservatively treated patients experience a lessening of symptoms over many years, even though two thirds of them still have objective evidence of the disease.²

Esophagitis, a complication of GERD, tends to become a relapsing, chronic condition. It recurs in 50 to 80 percent of affected patients within six to 12 months after the discontinuation of pharmacologic therapy.⁵ Other complications of GERD include strictures, ulcerations and Barrett's esophagus (progressive replacement of distal eroded squamous mucosa with metaplastic gastric epithelium). Patients with Barrett's esophagus have a 30 to 125 times greater risk of developing adenocarcinoma of the esophagus (even though the overall risk remains quite low).³ Younger age at onset and longer duration of symptoms seem to increase the risk of malignancy.³

Treatment of GERD associated with Barrett's esophagus has not been shown to eliminate the metaplasia of that condition or the risk of malignancy. Consequently, patients with Barrett's esophagus require periodic endoscopic biopsy to assess esophageal tissue for malignant changes.⁶

Pathophysiology


In the diagnosis of GERD, response of symptoms to treatment with a proton pump inhibitor is as sensitive and specific as the results of 24-hour pH monitoring.

GERD is thought to have a multifactorial etiology rather than a single cause. Contributing factors include the caustic materials that are refluxed, a breakdown in the defense mechanisms of the esophagus and a functional abnormality that results in reflux.

Offending Agents
Stomach secretions and contents are naturally at a lower pH than the normal esophageal environment. If these more acidic substances are not cleared rapidly from the esophagus, they can harm esophageal tissue. Acidic gastric material is undoubtedly the primary offending agent in the development of GERD, with duration of exposure being a key factor.¹

The role of bile acids from the duodenum is also being investigated. As many as 60 percent of patients with GERD reflux both gastric and duodenal juices.⁷ Although definite proof is lacking, bile acid reflux may be the reason that more severe esophagitis can be difficult to heal despite adequate suppression of gastric acid secretion.⁷

Defects and Abnormalities
The lower esophageal sphincter normally works in conjunction with the diaphragm to create a physical barrier against the entry of gastric contents into the esophagus.⁴ Transient relaxation of this sphincter may occur more often in patients with GERD.¹

Esophageal motility disorders and delayed gastric emptying may also be factors in the development of GERD.^1,4 The role of delayed gastric emptying remains controversial, but patients with gastroparesis have been shown to have a predisposition to reflux.⁸

The contribution of hiatal hernia to GERD is another source of controversy. Although the incidence of prolonged reflux appears to be increased with hiatal hernia, patients may have a hiatal hernia without reflux or reflux without a hernia.⁹

Other possible causal factors in GERD include delayed clearance of physiologic reflux by saliva, decreased secretion of bicarbonate by esophageal submucosal glands and attenuated ability of the cells lining the esophagus to resist acid injury.¹

Diagnosis

Clinical Presentation
When patients present with typical symptoms and no complications, the diagnosis of GERD is usually straightforward. The classic symptoms are heartburn and regurgitation, which may also include dysphagia.¹⁰

In the absence of classic symptoms, GERD becomes more difficult to diagnose. Other symptoms that may be caused by GERD are atypical chest pain, hoarseness, nausea, cough, odynophagia and asthma.¹¹ Symptoms that may indicate a more serious problem, such as chest pain (possible cardiac causes), dysphagia, odynophagia and weight loss (possible esophageal stricture or cancer), require more extensive investigation before the diagnosis of GERD can be established. Diagnostic tests are used when the diagnosis is in doubt or complications are a concern.

Response to Omeprazole
A recent study¹² demonstrated a potential role for a proton pump inhibitor, omeprazole (Prilosec), in the diagnosis of GERD. The response of symptoms to omeprazole, in a dosage of 40 mg per day for 14 days, was shown to be about as specific and sensitive for the diagnosis of GERD as the results of 24-hour pH monitoring. Because of the efficacy of omeprazole in relieving reflux symptoms, failure to respond to this proton pump inhibitor warrants investigation of other possible causes for a patient's symptoms.


Lifestyle modifications should be emphasized and incorporated into all stages of treatment.

Radiologic Findings
Only one third of patients with GERD have radiologic signs of esophagitis.¹³ Findings include erosions and ulcerations, strictures, hiatal hernia, thickening of mucosal folds and poor distensibility.^13,14 Only a minority of patients with documented abnormal pH have radiographically evident esophagitis.¹³Consequently, a radiographic study is not the test of choice for the diagnosis of GERD.

Endoscopy
Endoscopy is useful for diagnosing the complications of GERD, such as Barrett's esophagus, esophagitis and strictures, but it is not sensitive for diagnosis of GERD itself. Only 50 percent of patients with GERD manifest macroscopic evidence on endoscopy.¹²

Ambulatory pH Monitoring
Ambulatory pH monitoring is generally considered the diagnostic gold standard for use in patients with GERD. In this study, a pH monitor is placed in the esophagus above the lower esophageal sphincter, and the pH is recorded at given moments in time. Over the 24-hour test period, the patient writes down the time and situation in which symptoms occur, in the hope that symptoms can be correlated with the lowering of esophageal pH that occurs with reflux.

Esophageal pH monitoring may not be available in some areas. Furthermore, the test is time-consuming, and it can be inconvenient or troublesome for the patient. In addition, pH monitoring requires good technical placement of the probe and experienced interpretation of the results.^10,12


Management Stages for Gastroesophageal Reflux Disease


FIGURE 1. Management of gastroesophageal reflux disease.

Treatment

The management of GERD can be divided into five stages (Figure 1). Stages I through IV consist of medical management, and stage V entails surgical intervention. The ultimate goal of treatment is to minimize exposure of the esophagus to refluxate, thereby alleviating symptoms, healing the esophagus, preventing complications and maintaining remission.^4,15

Most patients with GERD achieve adequate symptom control and esophageal healing through a combination of lifestyle modifications and drug therapy and therefore do not require surgical intervention. Antireflux surgery may be required in patients who continue to have severe symptoms, erosive esophagitis or disease complications despite adequate pharmacologic therapy.^6,15

Stage I: Lifestyle Modifications
Lifestyle modifications are a key component in the management of GERD and should be incorporated into all treatment stages. Modifications include elevating the head of the bed by six inches, decreasing fat intake, stopping smoking, reducing alcohol consumption, losing weight, avoiding recumbency for three hours postprandially and not consuming large meals and certain types of food (Table 1).^5,16

Despite the lack of extensive clinical data supporting the effectiveness of lifestyle modifications as sole therapy, patients with GERD experience relief of mild to severe symptoms by incorporating these changes into their daily routine.^14,17 Many patients view lifestyle modifications as being somewhat inhibitive and impractical. However, it should be emphasized that stopping smoking and reducing fat and alcohol consumption not only improve GERD symptoms but also improve cardiopulmonary health and reduce the risk of certain types of cancer.¹⁷


TABLE 1 Dietary Factors Associated with Increased Reflux Symptoms*
Caffeinated products	Chocolate	Tomato-based products
Peppermint	Spicy foods	Alcohol
Fatty Foods	Citrus fruits and juices
*--Smoking also increases reflux and aggravates gastroesophageal reflux disease. Information from Fennerty MB, Castell D, Fendrick AM, Halpern M, Johnson D, Kahrilas PJ, et al. The diagnosis and treatment of gastroesophageal reflux disease in a managed care environment: suggested disease management guidelines. Arch Intern Med 1996;156:477-84, and DeVault KR, Castell DO. Guidelines for the diagnosis and treatment of gastroesophageal reflux disease. Arch Intern Med 1995;155:2165-73.

Stage II: 'As-Needed' Pharmacologic Therapy
In addition to lifestyle modifications, patients with mild symptoms often require periodic drug therapy for symptom relief. This is typically achieved through the as-needed use of antacids, alginic acid (a component of antacid products such as Gaviscon) or over-the-counter histamine H₂-receptor blockers.


TABLE 2 Adverse Effects of Antacids
Antacid	Potential adverse effects
Aluminum salts	• Constipation • Accumulation in patients with renal impairment • Hypophosphatemia • Osteomalacia (rare)
Calcium salts	• Constipation • Milk-alkali syndrome with high doses • Rebound hyperacidity (depends on dosage)
Magnesium salts	• Diarrhea • Accumulation in patients with renal impairment
Sodium bicarbonate*	• Milk-alkali syndrome with high doses
Magnesium- aluminum combinations	• Minor changes in bowel function
*--Antacids containing sodium bicarbonate should be avoided in sodium-restricted patients, such as those with hypertension or congestive heart failure.

Antacids and Alginic Acid. Antacids remain the drugs of choice for quick relief of symptoms associated with GERD.¹⁷ These agents act primarily by rapidly increasing the pH of the gastric refluxate. Although antacids are effective in relieving symptoms, they are not used as sole agents for achieving esophageal healing because of the high dosage requirements and consequent lack of patient compliance.

When antacids are included in the therapeutic regimen, patients must be instructed in appropriate dosing. For maximum relief of symptoms, antacids should be used as needed and should be taken immediately after meals if symptoms occur.

Patients treated with antacids also need to be aware of potential adverse effects (Table 2) and drug interactions. Antacids can interact with a number of drugs, including fluoroquinolones, tetracycline and ferrous sulfate. The mechanism may be alteration of the gastric pH, increase of the urinary pH or adsorption of the concomitant agent with resultant alteration of bioavailability.¹⁸

Alginic acid is a component of various antacid products. Rather than neutralizing gastric acid, it reacts with sodium bicarbonate in saliva to form sodium alginate. The sodium alginate floats on top of the gastric contents where it acts as a mechanical barrier, minimizing exposure of the esophagus to refluxate. Although alginic acid is theoretically beneficial, it does not appear to be clinically superior to antacids alone. Furthermore, antacid products containing alginic acid tend to be expensive.

Over-the-Counter H₂-Receptor Blockers. Four over-the-counter H₂-receptor blockers are currently available in the United States (Table 3) These agents are indicated for the prevention and relief of heartburn, acid indigestion and sour stomach. They are available in half of the dosage strength of the prescription products. Although over-the-counter H₂-receptor blockers do not act as rapidly as antacids, they provide longer relief of symptoms. Because of their slower onset of action, H₂-receptor blockers are primarily used to prevent GERD symptoms.

Stage III: Initiation and Titration of Scheduled Pharmacologic Therapy
Instead of as-needed treatment, scheduled pharmacologic therapy is required in patients who have moderate to severe symptoms with or without documented erosive esophagitis.^5,16 In this treatment stage, suppression of gastric acid through the use of pharmacologic agents remains the primary approach for reducing reflux symptoms, healing esophagitis and maintaining remission.

Clinical data indicate that esophageal healing is influenced by both the degree and duration of gastric acid suppression.^19,20 Healing rates increase in relation to the length of time that the intragastric pH remains above 4.¹⁹ The agents used in stage III treatment of GERD include scheduled H₂-receptor blockers, prokinetic agents and proton pump inhibitors. (Table 3). The choice of agent depends primarily on the severity of symptoms and the presence or absence of esophagitis.


TABLE 3 Medications Used in the Treatment of Gastroesophageal Reflux Disease
Drug		Dosage	Cost (generic price)*
Antacids (liquids and tablets)		As needed	$ 1 to 5
Over-the-counter H₂-receptor blockers
	Nizatadine (Axid AR)	75 mg twice daily as needed	9†
	Famotidine (Pepcid AC)	10 mg twice daily as needed	9†
	Cimetidine (Tagamet HB)	200 mg twice daily as needed	10†
	Ranitidine (Zantac 75)	75 mg twice daily as needed	9†
Prokinetic agents
	Cisapride (Propulsid)	10 mg two or four times daily	45 to 90
		20 mg four times daily	174
	Metoclopramide (Reglan)	10 mg four times daily	92 (20 to 30)
H₂-receptor blockers
	Cimetidine (Tagamet)	400 mg twice daily	101 (82)
		800 mg twice daily	179 (132 to 153)
	Famotidine (Pepcid)	20 mg twice daily	99
		40 mg twice daily	185
	Nizatadine (Axid)	150 mg twice daily	96
	Ranitidine (Zantac)	150 mg two‡ to four times daily	99 (88 to 177)
		300 mg twice daily	180 (162)
Proton pump inhibitors
	Lansoprazole (Prevacid)	15 mg once daily	105
		30 mg once daily	107
	Omeprazole (Prilosec)	10 mg once daily	104
		20 mg once daily	116
*--Estimated cost to the pharmacist based on average wholesale prices (rounded to the nearest dollar) for one month's supply unless otherwise noted, in Red book. Montvale, N.J.: Medical Economics Data, 1998. Cost to the patient will be greater, depending on prescription filling fee. †--For 30 tablets. Over-the-counter indications limit continued use of these products to two weeks or less. ‡--Brand-name dosage.

H₂-Receptor Blockers. Before proton pump inhibitors were introduced, H₂-receptor blockers were the agents of choice for treating reflux symptoms and healing esophagitis. They remain the mainstay of pharmacologic treatment.

H₂-receptor blockers act by inhibiting histamine stimulation of the gastric parietal cell, thereby suppressing gastric acid secretion.¹⁹ These agents only minimally inhibit parietal cell stimulation by gastrin and acetylcholine, and therefore are weak inhibitors of meal-stimulated acid secretion. They are most effective in suppressing nocturnal acid secretion.

When given in the standard dosages used for peptic ulcer disease, H₂-receptor blockers relieve the symptoms of mild to moderate GERD.^16,20,21 However, standard dosages of these agents are not highly effective in healing esophagitis because acid secretion is not completely inhibited.²⁰ When higher dosages and/or more frequent doses of H₂-receptor blockers are used, adequate symptom relief occurs in approximately 50 to 60 percent of patients, and esophageal healing occurs in approximately 50 percent of patients.⁴

In equivalent dosages, the various H₂-receptor blockers are equally effective in providing symptom relief, healing esophagitis and maintaining remission. Selection of a particular agent is largely based on cost. Currently, only cimetidine (Tagamet) and ranitidine (Zantac) are available in generic preparations.

H₂-receptor blockers are fairly well tolerated and rarely require discontinuation secondary to adverse effects. The most common adverse effects are headache, diarrhea and constipation. Drug interactions occur more frequently with cimetidine than with other H₂-receptor blockers. The increase in drug interactions is related to the ability of cimetidine to inhibit the metabolism of drugs through various cytochrome P450 isoenzyme systems (Table 4).¹⁸


TABLE 4 Potential Drug Interactions with Cimetidine (Tagamet)*
Warfarin (Coumadin)	Diazepam (Valium)
Phenytoin (Dilantin)	Metronidazole (Flagyl)
Propranolol (Inderal)	Lidocaine (Xylocaine)
Calcium channel blockers	Theophylline
Chlordiazepoxide (Librium)	Certain tricyclic antidepressants
*--Cimetidine reduces the hepatic metabolism and increases the drug levels of these drugs through an effect on certain microsomal enzyme systems. Information from Welage LS, Berardi RR. Drug interactions with antiulcer agents: considerations in the treatment of acid-peptic disease. J Pharm Pract 1994;7:177-95.

Prokinetic Agents. Rather than neutralizing acid, prokinetic agents increase both gastric emptying and lower esophageal sphincter pressure.⁶ Cisapride (Propulsid) acts by increasing acetylcholine concentrations in the myenteric plexus. Because of the cholinergic side effects associated with bethanechol (Urecholine) and the central nervous system side effects associated with metoclopramide (Reglan), these older prokinetic agents are no longer frequently prescribed.

In clinical trials, cisapride has been found to be equivalent to standard-dose H₂-receptor blockers in relieving reflux symptoms and healing the esophagus.^6,16,22 However, cisapride requires more frequent dosing and has a higher incidence of side effects and drug interactions.⁴

The side effects of cisapride are generally limited to abdominal cramping and diarrhea. According to recent labeling changes and an expanded black box warning, cisapride should not be used in conjunction with agents known to inhibit the cytochrome P450 3A4 isoenzyme system (Table 5).²³


TABLE 5 Potential Drug Interactions with Cisapride (Propulsid)
Increase cisapride to dangerous blood levels*	Predispose patients to fatal arrhythmias with cisapride†
Clarithromycin (Biaxin) Erythromycin Troleandomycin (Tao) Nefazodone (Serzone) Fluconazole (Diflucan) Itraconazole (Sporanox) Ketoconazole (Nizoral) Indinavir (Crixivan) Ritonavir (Norvir)	Class 1A antiarrhythmics Class III antiarrhythmics Certain tricyclic antidepressants Certain tetracyclic antidepressants Certain antipsychotics
*--These drugs increase cisapride blood levels by inhibiting the cytochrome P450 3A4 enzymes that metabolize cisapride. This can lead to fatal cardiac arrhythmias. †--Cisapride is contraindicated for concomitant use with medications that prolong the QT interval and thereby increase the risk for an arrhythmia. This list is not comprehensive. Information from Propulsid. Package insert. Titusville, N.J.: Janssen Pharmaceutica Inc., 1998.

Inhibition of the metabolism of cisapride and subsequent accumulation of the active drug can lead to prolongation of the QT interval and the ultimate development of serious, potentially fatal cardiac arrhythmias. Cisapride should also be avoided in patients who have a history of QT interval prolongation, who are taking medications known to increase the QT interval or who have conditions that may predispose them to develop arrhythmias.

The manufacturer of cisapride recommends that a baseline electrocardiogram be considered before cisapride therapy is initiated.²³


When equipotent doses are given, the various H₂-receptor blockers do not differ in efficacy.

Proton Pump Inhibitors. Omeprazole and lansoprazole (Prevacid) are the currently available proton pump inhibitors. These drugs strongly inhibit gastric acid secretion. They act by irreversibly inhibiting the H⁺-K⁺ adenosine triphosphatase pump of the parietal cell. By blocking the final common pathway of gastric acid secretion, the proton pump inhibitors provide a greater degree and duration of gastric acid suppression compared with H₂-receptor blockers.¹⁹ Clinical trials^{16,20,22,24-26} have clearly shown that the proton pump inhibitors provide better symptom control, esophageal healing and maintenance of remission than either H₂-receptor blockers or prokinetic agents.

Long-term use of proton pump inhibitors in humans has not been associated with an increased risk of gastric carcinoma, although this was initially a concern.²⁴ Prolonged use of the drugs has been associated with gastric atrophy; however, atrophy is more likely to be a problem in patients infected with Helicobacter pylori.^4,6

The proton pump inhibitors are fairly well tolerated. The most common side effects are nausea, diarrhea, constipation, headache and skin rash. Omeprazole and lansoprazole are more expensive than standard-dose H₂-receptor blockers or prokinetic agents. However, when prescribed appropriately to patients with severe symptoms or refractory disease, the proton pump inhibitors are more cost-effective because of their higher healing and remission rates and the consequent prevention of complications.⁴

Combination Therapy. The use of combination drug therapy is not justified in most patients with GERD.^5,27 The combination of an H₂-receptor blocker and cisapride has been shown to provide better symptom relief and healing rates than treatment using either agent alone.^5,22 However, compared to proton pump inhibitor therapy, this combined regimen is less effective and more costly, and it may be associated with an increased incidence of side effects and possible drug interactions.²⁷ The combination of an antisecretory agent and a prokinetic agent may be appropriate in a patient with delayed gastric emptying, such as a diabetic patient with gastroparesis.

Summary of Stage III Treatment. In a patient with moderate to severe symptoms but no documented erosive esophagitis, pharmacologic therapy is generally initiated with an H₂-receptor blocker or a prokinetic agent, and the targeted duration of therapy is eight to 12 weeks.

If the patient remains symptomatic, the dosage of the H₂-receptor blocker is maximized, or therapy is changed to a proton pump inhibitor. Therapy should be continued for another eight to 12 weeks. As previously mentioned, the diagnosis should be reconsidered if the patient remains symptomatic on high-dose (40 mg) proton pump inhibitor therapy.

The patient with erosive esophagitis documented by endoscopy should be given omeprazole or lansoprazole as initial therapy because of the higher healing rates associated with proton pump inhibitors.

Stage IV: Maintenance Therapy
GERD has a high recurrence rate because no currently available pharmacologic agent is able to correct the underlying cause or causes of the disease. The need for maintenance therapy depends largely on the severity of the disease and the persistence of symptoms after the withdrawal of initial pharmacologic therapy.


Combination drug therapy is not justified in most patients with GERD.

In most patients with mild symptoms, antacids or over-the-counter H₂-receptor blockers can be used as needed to help control symptoms. The lowest effective scheduled dosage of an H₂-receptor blocker or a prokinetic agent should be used in patients with nonerosive esophagitis and moderate to severe symptoms.

Patients with erosive esophagitis or complicated disease should be given one of the proton pump inhibitors because of the higher rates of remission associated with these agents.^22,24-26 The lowest effective dosage should be used to maintain remission.

Stage V: Surgery
Surgery may be considered in patients who fail medical therapy or develop complications of GERD.²⁸ Patients can fail medical therapy because of noncompliance, inability to afford medications, relapse of symptoms soon after medication is stopped or relapse of symptoms despite continuous use of medication. Possible complicating factors include large hiatal hernia, Barrett's esophagus, severe esophagitis, recurrent esophageal strictures and severe pulmonary symptoms.²⁸

Surgical intervention has been shown to provide long-term relief of symptoms in patients with GERD.⁹ The open Nissen fundoplication procedure has a cure rate of up to 90 percent. This operation can now be performed laparoscopically.⁶

Compared with an open procedure, the Nissen laparoscopic procedure has a similar success rate, but it can be performed in much less time (under two hours). With laparoscopic treatment, patients experience less pain and have fewer complications (e.g., splenic injury, deep vein thrombosis, infection).²⁸ Consequently, they have a shorter hospital stay and an earlier return to work.²⁸ The Toupet partial fundoplication can also be performed laparoscopically. The purpose of the Toupet and Nissen fundoplication procedures is to reduce a hiatal hernia and restore the competence of the gastroesophageal junction by constructing a valve mechanism.⁶

Each year members of two different medical faculties develop articles for "Practical Therapeutics." This article is one in a series coordinated by the Department of Family Practice at the University of Kentucky College of Medicine, Lexington. Guest editors of the series are Bryan F. Yeager, Pharm.D., Thomas Armsey, M.D., and Samuel C. Matheny, M.D., M.P.H.

The Authors

MARK SCOTT, M.D.,
is assistant professor and family practice residency director at the University of Kentucky College of Medicine, Lexington. Dr. Scott received his medical degree from Southern Illinois University School of Medicine, Springfield, and completed family practice residency training at Southern Illinois University, Decatur.

AIMEE R. GELHOT, PHARM.D.,
is assistant professor at the University of Kentucky Colleges of Pharmacy and Medicine, and ambulatory care specialist in the Department of Internal Medicine. Dr. Gelhot received her pharmacy degrees from the University of Cincinnati and completed a postdoctoral residency in pharmacy practice at the University of Kentucky.

Address correspondence to Aimee R. Gelhot, Pharm.D., University of Kentucky Medical Center, 800 Rose St., Room C-117, Lexington, KY 40536-0084. Reprints are not available from the authors.

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