Treating GERD: Can medication, lifestyle changes or surgery help?

Treatment of GERD includes several forms.

Lifestyle change

Lifestyle modifications include:

• Weight loss (if you are overweight)
• Avoiding alcohol, coffee, chocolate, citrus juice and tomato-based products, onions and peppermint
• avoiding large portions of food
• wait 3 hours after eating before lying down
• raising the head of the bed slightly

Lifestyle modifications are the first line of management for pregnant women with GERD.

Pharmacological therapy

• antacids

Antacids (drugs that reduce acidity in the stomach) were standard treatment in the 1970s and are still effective in controlling mild GERD symptoms. Antacids should be taken after each meal and at bedtime.

• H2 receptor antagonists and H2 blocker therapy

H2 receptor antagonists (histamine receptor blockers) are the first-line treatment for patients with mild to moderate symptoms and grade I-II esophagitis. Options include cimetidine, famotidine, ranitidine.

H2 receptor antagonists are effective for curing only mild esophagitis in 70% to 80% of patients with GERD and for providing maintenance therapy to prevent relapse.

Tachyphylaxis (rapid attenuation of the effect of repeated doses of a drug) has been observed. This suggests that pharmacological tolerance may reduce the long-term efficacy of these drugs.

In patients with severe disease (especially those with Barrett's oesophagus) who have experienced nocturnal acid breakthrough, further treatment with an H2 blocker is useful.

• Proton pump inhibitors (PPIs)

PPIs are the most potent drugs available for the treatment of GERD. These agents should only be used when the condition has been objectively documented.

They have few adverse effects. Their use may interfere with calcium metabolism and this may cause heart rhythm disturbances.

Long-term use of these drugs has also been associated with bone fractures in postmenopausal women, chronic kidney disease, acute kidney disease, community-acquired pneumonia and intestinal Clostridium difficile infection.

Available PPIs include omeprazole, pantoprazole, lansoprazole, rabeprazole, and esomeprazole. They are administered 30-45 minutes before meals (to achieve their maximum effect) once daily at standard dosing for 4 weeks.

The Agency for Healthcare Research and Quality survey concluded, based on Grade A evidence, that PPIs were superior to H2 receptor antagonists in resolving GERD symptoms at 4 weeks and in healing esophagitis at 8 weeks.

• prokinetic drugs and reflux inhibitors

Prokinetic agents are moderately effective, but only in patients with mild symptoms. Other patients usually require additional acid-suppressing medications such as PPIs. In adults, metoclopramide, itopride, and domperidone are used.

Long-term use of prokinetic agents can have serious, even potentially fatal, complications. Therefore, it should be avoided.

Long-term (maintenance) treatment of GERD

Symptoms or GERD itself will return in up to 80% of patients after discontinuation of antisecretory therapy within 1 year. Thus, long-term treatment is necessary for most patients.

The goal of long-term treatment is to use the mildest possible treatment (administering PPIs at the lowest possible dosage) that will guarantee the patient a symptom-free life and prevent the development of GERD complications.

To prevent recurrence of GERD, PPIs are recommended once daily in patients with NERD or in patients with mild erosive GERD.

Often the lowest possible dose, or dosing according to the patient's needs (on-demand therapy), is sufficient. Prokinetics are not recommended in this indication.

Surgical treatment

The most commonly performed surgery today in children and adults is the Nissen fundoplication. It is performed laparoscopically and is required in about 10% of patients with GERD.

Surgical treatment requires:

• Patients with symptoms that are not fully controlled with PPI therapy may be considered for surgery. Surgery may also be considered in patients with well-controlled GERD but who desire definitive, single-dose treatment
• Patients with oesophagitis or Barrett's oesophagus present are indicated for surgery
• Patients with extraesophageal manifestations of GERD may require the need for surgery. These manifestations include the following:
  1. Respiratory manifestations (e.g., coughing, wheezing, aspiration)
  2. ear, nose and throat manifestations (e.g. hoarseness, sore throat, otitis media)
  3. manifestations on teeth (e.g. enamel erosion)
• Young patients
• Poor patient cooperation (compliance) with medication
• Postmenopausal women with osteoporosis
• Patients with cardiac conduction disorders
• High cost of treatment