Colin W. Howden, MD Professor of Medicine, Division of Gastroenterology, Northwestern University, Feinberg School of Medicine, Chicago, IL William D. Chey, MD Associate Professor, Division of Gastroenterology, Director of the GI Physiology Laboratory, University of Michigan Health System, Ann Arbor, MI *This special section of The Journal of Family Practice is provided by an unrestricted grant fromTAPPharmaceutical Products, Inc. The authors received a stipend for this work. Dr. Howden reports that he serves on the speakers bureaus for Merck &Co., Inc., Novartis, TAP, and Wyeth, and he has been a consultant to Novartis, Prometheus Laboratories, Inc., Takeda Pharmaceuticals North America, TAP, and Wyeth. Dr. Chey reports that he has received grants and/or serves on speakers bureaus for AstraZeneca, Janssen, and TAP.
Dietary modifications. Patients should not consume large meals and should avoid lying down for 3 to 4 hours after eating. Caffeinated products, peppermint, fatty foods, chocolate, spicy foods, citrus fruits and juices, tomato-based products, and alcohol may contribute to episodes of GERD.18,21 Lozenges of any kind are able to stimulate salivary secretion, help clear refluxed acid, and hence, help relieve symptoms.
Lifestyle modifications. Changes in lifestyle may include such seemingly sensible interventions as sleeping with the head elevated, stopping smoking, and losing weight. There is little or no established evidence for the efficacy of these and other lifestyle modifications in the management of GERD. However, in1 trial of 63 patients, elevating the head of the bed with 6-inch blocks resulted in 1 less episode of heartburn or acid regurgitation per night when compared with lying flat.22 In another trial of 71 patients with esophagitis, elevating the bed was nearly as effective as ranitidine for reducing symptoms and producing endoscopically verifiable healing.23
Obstacles to effective GERD treatment in primary care
Arecent survey20 of 1046 primary care physicians found that:
36% instructed patients to take PPIs during or after a meal or did not specify a time of dosing
75% referred patients for surgical antireflux therapy and 20% referred patients directly to a surgeon without gastrointestinal consultation
15% reported that a trial with a H2 receptor antagonist was required by their healthsystem or insurance company prior to using a PPI.
Drug interventions
Pharmacological interventions include over-the-counter remedies such as antacids and H2RAs (Table 1), as well as prescription-only doses of H2RAs and PPIs. At the time of writing, no PPI was available in an over-the-counter preparation in the United States, although over-the-counter omeprazole may soon be approved. Many authorities believe an incremental approach to the management of GERD is appropriate, beginning with lifestyle modifications and over-the-counter preparations, continuing with H2 blockers, and reserving PPIs for nonresponders. While this approach may have appeal from a cost perspective, we believe another approach (as illustrated in the Figure) is clinically superior.
Antacids. Over-the-counter antacids rapidly increase the pH of the intraesophageal contents and also neutralize acidic gastric contents that might be refluxed. They are frequently used to treat heartburn. However, few clinical trials have evaluated the efficacy of antacids. Published trials24-26 are limited by small sample sizes and a lack of intention-to-treat analysis. Only 1 showed positive evidence for antacid efficacy.25
The utility of antacids is limited by the need for frequent dosing and possible interactions with such drugs as fluoroquinolones, tetracycline, and ferrous sulfate.27 Alginate/antacids have shown statistically significant benefit compared with placebo for relief of mild-to-moderate GERD symptoms and healing of esophagitis.24,28-34
H2receptor antagonists. H2RAs have shown positive effects on symptoms in some studies, although symptomatic response rates observed were only around 60% to 70%. Additionally, most of the trials to date have been for 2 to 6 weeks in duration.3543 An issue worthy of consideration with the H2RAs is the development of tolerance with continuous use.44
An H2RA-antacid combination was recently evaluated in a trial that compared it with monotherapy using either agent. Of the patients receiving combination therapy, 81% reported an excellent or good symptom response. Those receiving famotidine or atacid alone reported a 72% excellent or good symptom response.3
