Gastro-oesophageal reflux disease (GORD) Part 3
Posted by Eamonn Brady on
The two groups of acid-suppressing drugs available proton pump inhibitors (PPIs) and histamine receptor blockers (H2 blockers). PPIs are more effective and are used more often than H2 blockers.
Proton pump inhibitors work by completely blocking the production of stomach acid. Proton pump inhibitors include: omeprazole (Losec®, Romep®), lansoprazole (Zoton®, Zotrole®), pantoprazole (Protium®, Pantup®) rabeprazole (Pariet®, Razole®), and esomeprazole (Nexium®, Nexazole®). Side effects of PPIs are uncommon but may include headaches, diarrhoea, nausea, abdominal pain and constipation. There is no significant difference in efficacy between equivalent doses of proton pump inhibitors, including equivalent doses of esomeprazole (Nexium) and omeprazole. According to NICE in the UK, the decision to choose one over another should be based first on cost and second on individual patient response. Pantoprazole and esomeprazole have changed from POM to P in recent years meaning that pharmacists can now recommend them over the counter to their patients.
Interactions of PPIs
Reducing stomach acid can interfere with the absorption of some drugs. PPIs reduce the absorption of ketoconazole (anti-fungal medication) and can increase the absorption of digoxin (used for irregular heart rhythm). PPIs can also reduce the break-down of some drugs by the liver and lead to an increase in their concentration in the blood. Omeprazole is more likely than the other PPIs to reduce the break-down of drugs by the liver. PPIs can increase the concentration in the blood of diazepam, warfarin and phenytoin. PPIs can also reduce the concentration and effectiveness of clopidogrel (Plavix®), a drug used to prevent blood clots. If possible an H2 blocker and / or antacid should be considered instead of a PPI in these patients.
Histamine causes cells in the stomach to produce acid. H2-blockers stop histamine from working on these cells so they reduce acid in the stomach and include, famotidine (Pepcid®), nizatidine (Axid®) and ranitidine (Zantac®). Side effects are similar to PPIs but may also include a rash, dizziness and / or tiredness. Cimetidine is now rarely used as it interacts with many other drugs.
Drugs and stomach emptying
These drugs are designed to hasten the movement of food through the stomach and helping reduce stomach acid levels. They include domperidone (Motillium®, Domerid®) and metoclopramide (Maxolon®). Whilst they are not commonly used in the treatment of GORD they can help in some cases, especially if bloating or belching occurs. Recently, authorities have advised that domperidone should be used in caution in those with certain heart complaints (ie) A higher risk of cardiac adverse drug reactions observed in patients over 60 years old, adults taking daily oral doses of more than 30mg domperidone and those concomitantly taking QT-prolonging medicines or CYP3A4 inhibitors.
Surgery may be performed in severe cases where medication is not working.
Laparoscopic nissen fundoplication (LNF) is one of the most common types of surgery used to treat GORD. LNF is keyhole surgery that involves the surgeon making a series of small incisions in the stomach. During the procedure, the surgeon will wrap the upper section of the stomach around the oesophagus and staple it in place. By doing this, the lower oesophageal sphincter then tightens, which prevents acid moving back out of the stomach. LNF is carried out under general anaesthetic and takes 60 to 90 minutes to complete. Most people are discharged from hospital within 2-3 days with convalescence being 3-6 weeks.
Endoscopic injection of bulking agents involves injection of a combination of plastic and liquid into the area where the stomach and oesophagus meet (known as the gastro-oesophageal junction). This then narrows the junction and helps to prevent acid leaking up from the stomach.
Endoscopic augmentation with hydrogel implants is a relatively new technique. It is a similar technique to an endoscopic injection, except the surgeon uses gel to seal the oesophageal junction.
Endoluminal gastroplication involves the surgeon sowing a series of folds into the LOS. This restricts how far the LOS can open, preventing acid from leaking up from the stomach.
There are a number of self-care techniques that can help to relieve the symptoms of GORD.
- Targeting weight loss for those who are obese or overweight will help reduce the pressure on the stomach. This in turn will reduce the severity and frequency of symptoms
- Avoid tight-fitting clothing.Loose fitting clothing, especially trousers will reduce pressure on the abdomen and the lower oesophageal sphincter
- Stop Smoking
- Reduce or avoid consumption of heartburn inducing foods…..ie, fatty, fried or spicy. Reducing consumption of alcohol, chocolate and caffeine will also alleviate heartburn.
- Adjust eating habits. Little and often is easier for the digestive system to manage and process than the traditional 3 meals a day model.
- Avoid eating late in the evening to ensure that the stomach is empty at bedtime
- Drink alcohol only in moderation with meals
- Take your time and enjoy your food, take the time to chew and digest what you eat. Again, this puts less strain on your system as your stomach has to “work” less. The reverse is also true; eating quickly means the stomach does more work and exacerbates symptoms of GORD
- Avoid bending too much, especially after meals
- Raise the head of the bed by 8 inches by placing a piece of wood under it. This can help prevent stomach contents from rising up into the oesophagus
To be continued….next week GORD (Reflux) in infants and children.
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