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Gastroesophageal Reflux Disease. Scott Stolte, Pharm.D. Shenandoah University. Overview of GERD. Definition Symptoms or mucosal damage produced by the abnormal reflux of gastric contents into the esophagus Classic symptom is frequent and persistent heartburn

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Gastroesophageal reflux disease l.jpg

Gastroesophageal Reflux Disease

Scott Stolte, Pharm.D.

Shenandoah University

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Overview of GERD

  • Definition

    • Symptoms or mucosal damage produced by the abnormal reflux of gastric contents into the esophagus

  • Classic symptom is frequent and persistent heartburn

  • 44 % of Americans experience heartburn at least once per month

  • 7 % have daily symptoms

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Normal Function

  • Esophagus

    • Transports food from mouth to stomach through peristaltic contractions

  • Lower esophageal sphincter (LES)

    • Relaxes, on swallowing, to allow food to enter stomach and then contracts to prevent reflux

  • Normal to have some amount of reflux multiple times each day (transient relaxation of LES – not associated with swallowing)

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  • 3 lines of defense must be impaired for GERD to develop

    • LES barrier impairment

      • Relaxation of LES

      • Low resting LES pressure

      • Increased gastric pressure

    • Decreased clearance of refluxed materials from esophagus

    • Decreased esophageal mucosal resistance

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Decrease LES pressure



Fatty meals

Coffee, cola, tea




Directly irritate the gastric mucosa

Tomato-based products


Spicy foods

Citrus juices

Meds: NSAIDS, aspirin, iron, KCl, alendronate

Stimulate acid secretions




Contributing Factors

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Contributing Factors

  • Drugs that decrease LES pressure

    • Alpha-adrenergic agonists

    • Anti-cholinergic agents (e.g. TCA’s, antihistamines)

    • Beta-adrenergic agonists

    • Calcium channel antagonists (nifedipine most reduction)

    • Diazepam

    • Dopamine

    • Meperidine

    • Nitrates/Other vasodilators

    • Estrogens/progesterones (including oral contraceptives)

    • Prostaglandins

    • Theophylline

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Lines of Defense

  • Clearance of refluxed materials from esophagus

    • Primary peristalsis from swallowing – increases salivary flow

    • Secondary peristalsis from esophageal distension

    • Gravitational effects

  • Esophageal mucosal resistance

    • Mucus production in esophagus

    • Bicarbonate movement from blood to mucosa

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  • Amount of esophageal damage seen dependent on:

    • Composition of refluxed material

      • Which is worse: acid or alkaline refluxed material?

    • Volume of refluxed material

    • Length of contact time

    • Natural sensitivity of esophageal mucosa

    • Rate of gastric emptying

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Typical Symptoms

  • Common symptoms most common when pH<4

    • Heartburn

    • Belching and regurgitation

    • Hypersalivation

  • May be episodic or nocturnal

  • May be aggravated by meals and reclining position

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Atypical Symptoms

  • Nonallergic asthma

  • Chronic cough

  • Hoarseness

  • Pharyngitis

  • Chest pain (mimics angina)

  • May be only symptoms – “omeprazole test”

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  • Esophagitis

  • Esophageal strictures and ulcers

  • Hemorrhage

  • Perforation

  • Aspiration

  • Development of Barrett’s esophagus

  • Precipitation of an asthma attack

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Barrett’s Esophagus

  • Highest prevalence in adult Caucasian males

  • Histologic change

    • Lower esophageal tissue begins to resemble the epithelium in the stomach lining

  • Predisposes to esophageal cancer (30-60x) and esophageal strictures (30-80% increased risk)

  • Odds ratio for development (compared with GERD < 1 yr.)

    • Patients with GERD 1-5 years – 3.0

    • Patients with GERD > 10 years – 6.4

  • More frequent, more severe, and longer-lasting the symptoms of reflux, the > the risk of cancer

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Warning Signs

If present, consider an endoscopy:

  • Dysphagia

  • Odynophagia

  • Bleeding

  • Unexplained weight loss

  • Choking

  • Chest pain

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  • Clinical symptoms and history

    • Presenting symptoms and associated risk factors

  • Give empiric therapy and look for improvement

  • Endoscopy if warning signs present

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  • Chest pain

  • Heartburn while taking H2RAs or PPIs

    • Or heartburn that continues after 2 weeks of treatment

  • Nocturnal heartburn symptoms

  • Frequent heartburn for > 3 months

  • GI bleeding and other warning signs

  • Concurrent use of NSAIDS

  • Pregnant or nursing

  • Children < 12 years old

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Therapy Goals

  • Alleviate or eliminate symptoms

  • Diminish the frequency of recurrence and duration of esophageal reflux

  • Promote healing – if mucosa is injured

  • Prevent complications

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  • Therapy is directed at:

    • Increasing LES pressure

    • Enhancing esophageal acid clearance

    • Improving gastric emptying

    • Protecting esophageal mucosa

    • Decreasing acidity of reflux

    • Decreasing gastric volume available to be refluxed

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  • Three phases in treatment

    • Phase I: Lifestyle changes – 2 weeks

      • Lifestyle modifications

      • Patient-directed therapy with OTC medications

    • Phase II: Pharmacologic intervention

      • Standard/high-dose antisecretory therapy

    • Phase III: Surgical intervention

      • Patients who fail pharmacologic treatment or have severe complications of GERD

      • LES positioned within the abdomen where it is under positive pressure

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Treatment Selection

  • Mild intermittent heartburn (Phase I)

    • Treat with lifestyle changes plus antacids AND/OR low dose OTC H2-receptor antagonists (H2RA’s) as needed

  • Symptomatic relief of mild to moderate GERD (Phase II)

    • Treat with lifestyle changes plus standard doses of H2RA’s for 6-12 weeks ORproton pump inhibitors (PPI’s) for 4-8 weeks

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Treatment Selection

  • Healing of erosive esophagitis or treatment of moderate to severe GERD (Phase II)

    • Lifestyle modifications plus PPI’s for 8-16 weeks OR high dose H2RA’s for 8-12 weeks

      • PPI’s preferred as initial choice due to more rapid symptom relief and higher rate of healing

    • May also add a prokinetic/promotility agent

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Treatment Considerations

  • Prokinetic agents are an alternative to H2RA’s

    • Efficacy similar to prescription dose H2RA’s

    • Used as a single agent only in mild to moderate, nonerosive GERD

    • May be more expensive and use is limited by side effects

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Treatment Considerations

  • Maintenance therapy may be needed

    • Large % of patients experience recurrence within 6-12 months after D’C of therapy

    • Goal is to control symptoms and prevent complications

    • May use antacids, PPIs or H2RAs

      • In patients with more severe symptoms, PPI most effective

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Lifestyle Modifications

  • Elevate the head of the bed 6-8 inches

  • Decrease fat intake

  • Smoking cessation

  • Avoid recumbency for at least 3 hours post-prandial

  • Weight loss

  • Limit alcohol intake

  • Wear loose-fitting clothing

  • Avoidance of aggravating foods

  • These changes alone may not control symptoms

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Esophageal mucosal resistance: Alginic acid, Sucralfate

Esophageal clearance: Cisapride

LES pressure: MetoclopramideCisapride

Gastric emptying: Metoclopramide Cisapride

Gastric acid: Antacids H2RAs PPIs

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Drug Therapy - Antacids

Antacids with or without alginic acid

  • Antacids increase LES pressure and do not promote esophageal healing

    • Neutralize gastric acid, causing alkalinization

  • Alginic acid (in Gaviscon) forms a highly viscous solution that floats on top of the gastric contents

  • Dose as needed – typical action – 1-3 hours

  • Not best choice for nocturnal symptoms because pH suppression cannot be maintained

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Drug Therapy - Antacids

  • Products: Magnesium salts, aluminum salts, calcium carbonate, and sodium bicarbonate

  • Dosing: Initially 40-80 mEq prn (no more than 500-600 mEq per 24 hours)

    • Maalox/Mylanta 30 ml prn or PC & HS

    • Maalox TC/Mylanta II 15 ml prn or PC & HS

    • Gaviscon 2 tabs PC & HS

    • Tums 0.5-1 gm prn

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Drug Therapy – H2RA’s


  • Mainstay of treatment for mild to moderate GERD

  • H2RA’s equally efficacious

    • Select based on pharmacokinetics, safety profile and cost

  • Timing

    • Give in divided doses for constant gastric acid suppression

    • May give at night if only nocturnal symptoms

    • Give before an activity that may result in reflux symptoms

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Drug Therapy – H2RA’s

  • Response to H2RA’s dependent upon:

    1) Severity of disease

    2) Duration of therapy

    3) Dosage regimen used

  • Tolerance to effect develops

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Drug Therapy - PPI’s

Proton Pump Inhibitors

  • Used to treat moderate to severe GERD

  • More effective and faster healing than H2RA’s

    • May be used to treat esophagitis refractory to H2RA’s

  • All agents effective - choose based on cost

  • Prilosec released OTC 2003

    • Use for heartburn that occurs ≥ 2 days/week

    • Label - Don’t use for more than 14 days

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Drug Therapy - PPI’s

  • Standard dosing

    • Esomeprazole 20 mg qd

      • May 2006: FDA approved Nexium for adolescents 12-17 years for the short-term (up to 8 weeks) treatment of GERD

    • Lansoprazole 15-30 mg qd

    • Omeprazole 20 mg qd

    • Pantoprazole 40 mg qd

    • Rabeprazole 20 mg qd

  • Timing

    • Best is 30 minutes prior to breakfast

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Drug Therapy - PPI’s

  • May give higher doses bid for

    • Patients with a partial response to standard therapy

    • Patients with breakthrough symptoms

    • Patients with severe esophageal dysmotility

    • Patients with Barrett’s esophagus

  • Always give second dose 30 minutes prior to evening meal

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Drug Therapy - Prokinetics

Prokinetic Agents -- MOA

  • Enhances motility of smooth muscle from esophagus through the proximal small bowel

  • Accelerates gastric emptying and transit of intestinal contents from duodenum to ileocecal valve

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Drug Therapy - Prokinetics

Prokinetic Agents

  • Results of therapy

    • Improved gastric emptying

    • Enhanced tone of the lower esophageal sphincter

    • Stimulated esophageal peristalsis (cisapride only)

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Prokinetic Agents - Products

Metoclopramide (Reglan)

  • Dopamine antagonist

  • Only use if motility dysfunction documented

  • Administer at least 30 minutes prior to meals

  • Dose - 10 to 15 mg AC and HS

  • Adverse Effects – limit use

    • diarrhea

    • CNS - drowsiness, restlessness, depression

    • extrapyramidal reactions – dystonia, motor restlessness, etc.

    • breast tenderness

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Prokinetic Agents - Products


  • Was removed from the market July 14, 2000 due to adverse cardiovascular effects (i.e. ventricular arrhythmias)

  • Available only through an investigational limited access program for patients who have failed all other treatment options

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Drug Therapy – Mucosal Protectants

  • Sucralfate

    • Very limited value in treatment of GERD

    • Comparisons

      • Similar healing rate to H2RA in treatment of mild esophagitis

      • Less effective than H2RAs in refractory esophagitis

    • Only use in mildest form of GERD

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Special Populations

  • Infants can experience a form of GERD

    • Postmeal regurgitation or small volume vomiting

    • Occurs due to a poorly functioning sphincter

    • Treatment

      • Supportive therapy

        • Diet adjustments – smaller, more frequent feedings; thickened feedings

        • Postural management

      • H2RA’s have been used (e.g. ranitidine 2 mg/kg) and antacids

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Special Populations

  • Pregnancy

    • Common, due to decreased LES pressure and increased abdominal pressure

    • Nearly half of all pregnant women experience

    • Antacids other than sodium bicarbonate generally considered safe, but avoid chronic high doses

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GERD in the Elderly

  • In the US, 20% report acid reflux

  • Worldwide, 3X prevalence in > 70 yo of patients younger than 39 yo

  • More likely to develop severe disease

  • More likely to be poorly diagnosed or underdiagnosed

    • Due to atypical symptoms

  • Always look for medication causes

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GERD in the elderly

  • Symptoms

    • Dysphagia

    • Vomiting

    • Weight loss

    • Anemia

    • Anorexia

  • Typical symptoms are less frequent

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GERD in the Elderly

  • Diagnosis should always include endoscopy

  • Prokinetic agents should be avoided

  • PPI’s are medications of choice for acute episodes and prevention of recurrence due to efficacy, safety, and tolerability

    • Step down approach is preferred – more clinically effective and more cost effective

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PPIs in the Elderly

  • Decreased clearance with omeprazole, lansoprazole, rabeprazole

  • Little effect on clearance with pantoprazole

  • Dosage adjustments not necessary

  • Pantoprazole – lower affinity for CYP450

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Counseling Questions

  • Before recommending a therapy, ask:

    • Duration and frequency of symptoms

    • Quality and timing of symptoms

    • Use of alcohol and tobacco

    • Dietary choices

    • Medications already tried to treat symptoms

    • Other disease states present and medications being used

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Case Study

  • BT, a 45 year old male postal worker, complains of heartburn 3-4 times per month. The pain typically appears after meals. He has tried Tums with varying degrees of success. He would like something “more effective.”

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Case Study

  • What questions should you ask BT first?

  • What would cause you to refer BT to a physician?

  • What type of GERD do you think BT has- mild, moderate or severe?

  • What treatment should you recommend?