Medications for Gastric Reflux
By Jillian Foglesong Stabile. MD
Gastroesophageal Reflux, also known as GERD/reflux/heartburn, is a usually painful condition. It’s caused by inappropriate relaxation of the muscle at the base of the esophagus called the lower esophageal sphincter (LES). When the LES relaxes, stomach contents and acid can move from the stomach back into the esophagus. This can cause abdominal or chest pain, burning, the sensation of a lump in the throat, trouble swallowing, cough, belching, hoarseness, and regurgitation of food. In some cases, GERD can also cause a chronic cough, inflammation of the vocal cords, and asthma or worsening of asthma.
Who gets reflux?
Reflux is an extremely common condition. It is estimated that as many as 10-20% of people in the Western world have GERD. In the United States, the frequency may be as high as 28%. GERD is more common in people who have obesity, drink alcohol excessively, use tobacco, or are pregnant. People from a lower socioeconomic status are also at increased risk. Certain medical problems such as connective tissue disorders or autoimmune diseases can also make you more likely to develop GERD. Many classes of medications can also contribute.
What are the complications of reflux?
Reflux is painful, but it can also cause more significant conditions. If reflux is left untreated, it can cause inflammation in the esophagus called esophagitis. Other potential complications include precancerous changes called Barrett’s esophagus, erosions, ulcerations of the esophagus, narrowing of the esophagus (esophageal stricture), or bleeding from the gastrointestinal (GI) tract.
Barrett’s esophagus
Barrett’s esophagus is a precancerous change in the lining of the esophagus. The lining is normally made up of squamous cell epithelium. With repeated exposure to stomach acid, the type of cells lining the esophagus change to a columnar form of epithelium. Another type of cell called goblet cells also develops. This can progress to adenocarcinoma, a form of cancer.
GI bleed
GI bleeding can present in several different ways. Blood in vomit or stool is always a cause for concern. But you don’t have to see red blood for it to be present. Black, tarry stools can also be a sign of GI bleeding. Bleeding related to reflux can be mild or can be severe enough to cause anemia, and in extreme cases, can be life-threatening.
Esophageal stricture
Esophageal stricture is a narrowing of the esophagus, which can make it difficult to swallow. Generally, the difficulty swallowing will start with a sensation of food sticking in the throat and progress to difficulty swallowing food or medications. As it gets worse, it can become difficult to swallow liquids as well. Pain with swallowing may also be present.
How is reflux diagnosed?
Reflux is usually diagnosed based on symptoms. Heartburn and regurgitation are the most common symptoms. Generally, a trial of acid-reducing medication will be recommended. Improvement of symptoms with acid-suppressing medications can confirm the diagnosis. If symptoms don’t respond or if more concerning symptoms are present, your healthcare provider may recommend additional testing. Testing may be used to evaluate for the complications of reflux, not just for the diagnosis itself. Testing can be performed using esophageal pH monitoring, esophageal pressure monitoring, or upper endoscopy.
pH monitoring
pH monitoring is usually performed using a capsule or a catheter in the nose. It may be done on or off of acid-suppressing medications.
Upper endoscopy
Upper endoscopy, also known as esophagogastroduodenoscopy or EGD, is used most commonly to evaluate reflux and its complications. EGD involves putting a camera through the mouth into the esophagus, stomach, and the first part of the small intestine, the duodenum. The lining of this part of the GI tract can be visualized, and if necessary, biopsied. EGD is used to look for Barrett’s esophagus, esophagitis, and esophageal cancer.
Non-medication options for treating reflux
Lifestyle changes and dietary modifications can treat reflux alone or in combination with medications. Weight loss, elevating the head of the bed, avoiding meals at night, eating smaller meals, and avoiding trigger foods may all help improve symptoms. If your heartburn and reflux symptoms occur at night, you may try avoiding eating within 3 hours of bedtime. Trigger foods include alcohol, caffeine, chocolate, and mint.
Medical treatment for reflux
If lifestyle modifications don’t control reflux symptoms, your healthcare provider may recommend medication. Many medications can treat reflux. Some of the medications are available over the counter, and others are available by prescription.
Antacids
Antacids commonly used as first-line medications for reflux Antacid medications are medications such as calcium carbonate, aluminum hydroxide, magnesium hydroxide, and Bismuth Subsalicylate. These medications do not require a prescription. These medications work to neutralize acid in the stomach to alleviate pain, relieve spasms, and avoid digestion and corrosion by acid. Antacids are usually taken on an as-needed base for symptoms. Side effects of antacids include constipation, abdominal pain, cramping, nausea, vomiting, increased gas, decreased appetite, or anemia. Before starting antacid therapy, you should talk with your healthcare provider. Antacid therapy may affect the absorption of medications and can affect the way they work. Antacid medications shouldn’t be used with certain medical conditions.
Histamine-2 (H2) receptor blockers
H2 receptor blockers are available over-the-counter but may also be prescribed in some circumstances. These medications are FDA-approved for the short-term treatment of uncomplicated GERD, ulcers, and heartburn. They are also used for off-label use of other gastrointestinal conditions. These medications are first-line and generally safe for use in pregnancy. Currently, three medications in this class are available for use in the United States. Famotidine (Pepcid) and Cimetidine (Tagamet) are both available over-the-counter or as prescriptions. Nizatidine (Axid AR) is only available as a prescription. Ranitidine (Zantac) was previously available as an over-the-counter and prescription in this class but was withdrawn from the market in the United States in April of 2020 due to concerns about the presence of N-Nitroso dimethylamine (NDMA), a cancer-causing chemical.
Side effects of H2 receptor blockers include headache, fatigue, abdominal pain, constipation, or diarrhea. In patients with certain medication problems, delirium, confusion, hallucinations, or slurred speech may occur. While all of these medications may affect the absorption of medications because of their acid-lowering effects, cimetidine is well known to have potentially serious interactions with many medications. Cimetidine is also associated with breast development in men, decreased sperm counts, impotence, and, in women, nipple discharge. For this reason, cimetidine is used less frequently than some of the other medications in this class. H2 blockers should not be used for more than 2 weeks at a time without consulting a healthcare professional.
Proton pump inhibitors
Proton pump inhibitors are a very commonly used class of medications for reflux and some of the complications associated with reflux. Proton pump inhibitors work by blocking enzyme-containing cells in the stomach lining that allow for acid secretion into the stomach. There are six FDA-approved medications in this class:
- Omeprazole (Prilosec)
- Esomeprazole (Nexium)
- Lansoprazole (Prevacid)
- Dexlansoprazole (Dexilant)
- Pantoprazole (Protonix)
- Rabeprazole (AcipHex)
Proton pump inhibitors may take a few days to achieve full effect, and as such are less useful for acute symptoms than for longer-term management of reflux symptoms. They are generally taken at least 30 minutes before eating because the proton pumps in the stomach are activated by meals.
Common side effects of proton pump inhibitors include headache, rash, dizziness, nausea, abdominal pain, gas, constipation, and diarrhea. They are generally very well tolerated by most people, but the risk of side effects increases with the length of time that you are on the medications.
Proton pump inhibitors may increase the risk of some infections because stomach acid is one of the barriers to infection that the body employs to protect itself. They can also decrease the absorption of certain vitamins such as vitamin B12, and in rare cases, magnesium. In people who have been on proton pump inhibitors for long periods, stopping the medications may cause rebound acid secretion. There are conflicting reports as to whether proton pump inhibitors may increase the risk of osteoporosis and bone fractures.
Proton pump inhibitors are contraindicated in certain conditions such as liver dysfunction, use of certain medications, and people who are known to be sensitive to medications in the class. Some people with these conditions may be started on the medication but should be carefully monitored by their healthcare provider for side effects and complications.
If your healthcare provider has diagnosed you with reflux or any other health condition, you may be wondering how to save money on your medications. Check out America’s Pharmacy prescription discounts to help find the best prices in your area.
Dr. Foglesong Stabile is a board-certified Family Physician who enjoys full scope Family Medicine, including obstetrics, women’s health, and endoscopy, as well as caring for children and adults of all ages. She also teaches the family medicine clerkship for Pacific Northwest University of Health Sciences.
References:
https://www.mayoclinic.org/diseases-conditions/gerd/symptoms-causes/syc-20361940
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8754510/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4133436/
https://www.ncbi.nlm.nih.gov/books/NBK526049/
https://www.ncbi.nlm.nih.gov/books/NBK525994/