Proton Pump Inhibitors for GORD

Gastro-oesophageal reflux disease (GORD) is a condition in which stomach acid 'backs up' into the oesophagus (the tube connecting the mouth to the rest of the gastro-intestinal system). This disorder, also known as GERD or acid reflux, may cause the taste of acid or bile in the back of the throat, discomfort, and pain in severe cases. GORD may be mild, moderate or chronic, and may also increase the risk of other gastrointestinal disorders. The development of Barrett's oesophagus, a condition in which the cells of this tube are transformed or altered in a way that makes them resemble cells of the small intestine, may be influenced by pre-existing GORD. This disorder, in turn, increases the risk of cancer in the upper gastric tract.

Other consequences of GORD include inflammation and wearing away of the lining of the oesphagus over time, which may lead to blood loss. GORD may develop as a result of the decreased integrity of the connection between the oesophagus and stomach.

This is mostly controlled by the lower oesophageal sphincter, a muscular valve that should relax to allow food into the stomach, and then contract when eating (or rather swallowing) has stopped.  However, in the course of the progression of GORD, this valve becomes increasingly relaxed at inappropriate times, which may result in the involuntary regurgitation of acid (and possibly undigested food particles) back up into the throat.

This is known as transient lower oesophageal sphincter relaxation.

The risk of developing GORD may be affected by many factors and other conditions. These include:

• Pregnancy: Approximately 66% of women may develop GORD while pregnant. This may be due to impaired stomach capacity, digestion and the reduced function of muscles that control swallowing.
• Cystic fibrosis: Up to 80% of cystic fibrosis patients may have increased acid reflux. This may be due to decreased pressure of the lower oesophageal sphincter.
• Lifestyle choices: Habitual tobacco-smoking or regular alcohol intake is also associated with the increased risk of developing GORD.
• Diet: Some foods have been known to increase the risk of GORD. These include fatty foods, caffeinated drinks, soft drinks, chocolate and spicy food. Additionally, portion control is an important component of reducing GORD, as over consumption can lead to symptoms of GORD.

Treatment For GORD

GORD may be treated with a lifestyle and dietary modifications and medication. These include:

Lifestyle and dietary modifications

Intermittent eating patterns are strongly associated with the development of GORD.

• In the case of GORD during pregnancy, the pressure on the stomach may be alleviated by taking increased amounts of small meals during the day, rather than three or four larger ones.
  ​
• GORD may occur while sleeping; therefore, raising the head of a bed by about 15cm to reduce mechanical stress on the stomach during this time, may be helpful.
   
• Snacking between meals may further distend the stomach and increase lower oesophageal sphincter relaxation. This may be addressed by implementing and maintaining a more regular meal-based eating regimen, with reduced snacking and more fluids between meals.
   
• Weight loss may be associated with an improved response to treatment in patients with GORD.
   
• Patients with GORD may also benefit from a reduced intake of acidic foods and polyunsaturated fatty acids.

Antacids

These are products containing such ingredients as sodium bicarbonate or calcium carbonate, which can neutralise hydrochloric acid (HCl), which is produced in the stomach to break down food, and may be pushed back up through the oesophagus in an attack of GORD. Pregnant women should not take antacids containing sodium bicarbonate, as they may increase water retention.

Histamine Blockers

These are histamine receptor-2 (H2) antagonists, that can prevent the production of HCl from cells in the stomach lining. This will reduce the availability of acid to irritate or inflame the oesophagus at the onset of GORD. The most common choice is ranitidine.

Proton Pump Inhibitors

If the above treatment options fail or patients require long-term relief, patients may be advised to switch to proton pump inhibitors (PPI's). These drugs also reduce stomach acid production by decreasing the availability of the molecular 'raw materials' required by cells to do so. Proton pump inhibitors are indicated for many symptoms and complications of GORD.

References

1. Badillo R, Francis D. Diagnosis and treatment of gastroesophageal reflux disease. World journal of gastrointestinal pharmacology and therapeutics. 2014;5(3):105-112.
2. DeMeester SR, DeMeester TR. The diagnosis and management of Barrett's esophagus. Advances in surgery. 1999;33:29-68.
3. Haidry R, Banks M, Gupta A, et al. OC-014 Patients With Intramucosal Carcinoma Arising In Barrett's Eosophagus Have Similar Outcomes To Those With High Grade Dysplasia: Data From The United Kingdom Registry. Gut. 2014;63 Suppl 1:A7.
4. Gilbert EW, Luna RA, Harrison VL, Hunter JG. Barrett's esophagus: a review of the literature. Journal of gastrointestinal surgery : official journal of the Society for Surgery of the Alimentary Tract. 2011;15(5):708-718.
5. Pauwels A, Blondeau K, Dupont LJ, Sifrim D. Mechanisms of increased gastroesophageal reflux in patients with cystic fibrosis. The American journal of gastroenterology. 2012;107(9):1346-1353.
6. Dall'Alba V, Fornari F, Krahe C, Callegari-Jacques SM, Silva de Barros SG. Heartburn and regurgitation in pregnancy: the effect of fat ingestion. Digestive diseases and sciences. 2010;55(6):1610-1614.
7. Richter JE. Gastroesophageal reflux disease during pregnancy. Gastroenterology clinics of North America. 2003;32(1):235-261.
8. Ali RA, Egan LJ. Gastroesophageal reflux disease in pregnancy. Best practice & research. Clinical gastroenterology. 2007;21(5):793-806.
9. Anton C, Anton E, Drug VL, Stanciu C. [Hormonal influence on gastrointestinal reflux during pregnancy]. Revista medico-chirurgicala a Societatii de Medici si Naturalisti din Iasi. 2003;107(4):798-801.
10. Pouderoux P, Verdier E, Kahrilas PJ. Patterns of esophageal inhibition during swallowing, pharyngeal stimulation, and transient LES relaxation. Lower esophageal sphincter. American journal of physiology. Gastrointestinal and liver physiology. 2003;284(2):G242-247.
11. Slomski A. Gastroesophageal reflux symptoms abate when smoking stops. JAMA : the journal of the American Medical Association. 2014;311(4):349.
12. Rubenstein JH, Chen JW. Epidemiology of gastroesophageal reflux disease. Gastroenterology clinics of North America. 2014;43(1):1-14.
13. Yasawy MI, Randhawa MA. GERD is becoming a challenge for the medical profession: is there any remedy? Hepatogastroenterology. 2014;61(134):1623-1626.
14. de Bortoli N, Guidi G, Martinucci I, et al. Voluntary and controlled weight loss can reduce symptoms and proton pump inhibitor use and dosage in patients with gastroesophageal reflux disease: a comparative study. Diseases of the esophagus : official journal of the International Society for Diseases of the Esophagus / I.S.D.E. 2014.
15. Fill S, Malfertheiner M, Costa SD, Monkemuller K. [Handling of the gastroesophageal reflux disease (GERD) during pregnancy--a review]. Zeitschrift fur Geburtshilfe und Neonatologie. 2007;211(6):215-223.
16. Galdon Castillo A, Galera Mendoza L, Egea Gonzalez A, Gonzalez Olsen A, Sanchez Gonzalez Y, Paniagua Soto J. [Disorders affecting the digestive system during sleep]. Revista de neurologia. 2004;38(8):757-765.
17. Csendes A, Burdiles P. [Scientific foundations for medical treatment based on modifying diet, lifestyle habits, and patient attitudes in chronic gastroesophageal reflux disease]. Cirugia espanola. 2007;81(2):64-69.
18. McRorie JW, Jr., Gibb RD, Miner PB, Jr. Evidence-based treatment of frequent heartburn: The benefits and limitations of over-the-counter medications. Journal of the American Association of Nurse Practitioners. 2014;26(6):330-339.
19. Quartarone G. Gastroesophageal reflux in pregnancy: a systematic review on the benefit of raft forming agents. Minerva ginecologica. 2013;65(5):541-549.
20. McDonagh MS, Carson S, Thakurta S. Drug Class Reviews. Drug Class Review: Proton Pump Inhibitors: Final Report Update 5. Portland (OR): Oregon Health & Science University, Portland, Oregon; 2009.
21. Abraham NS. Proton pump inhibitors: potential adverse effects. Current opinion in gastroenterology. 2012;28(6):615-620.
22. [Comparison of the effectiveness omeprazole and pantoprazole in the treatment of gastroesophageal reflux disease in patients with asthma]. Likars'ka sprava / Ministerstvo okhorony zdorov'ia Ukrainy. 2013(6):47-53.