Anti-reflux medications are highly effective and serve as an important foundation for the treatment of bothersome GERD-related symptoms. Three common medications for the treatment of GERD are H2 Blockers, Proton Pump Inhibitors (PPIs), Potassium competitive acid blockers (PCABs) and Promotility agents.
H2 blockers
H2 blockers reduce the amount of acid produced in the stomach and can help with symptoms when used as an as-needed medication. They are Famotidine (Pepcid AC®, Pepcid Oral®, Zantac 360®), Cimetidine (Tagamet®, Tagamet HB®), Nizatidine Capsules (Axid AR®, Axid Capsules®, Nizatidine Capsules®) and Ranitidine (Zantac®). H2 blockers are not appropriate to treat complications of GERD such as esophagitis (inflammation of the esophagus), esophageal stricture (narrowing caused by longstanding inflammation that increases scar tissue) or Barrett’s esophagus (a potentially pre-cancerous condition).
Proton pump inhibitors (PPIs)
PPIs reduce the amount of acid produced in the stomach, can help with symptoms, and are stronger than H2 blockers. They are Omeprazole (Prilosec®), Esomeprazole (Nexium®), Lansoprazole (Prevacid®), Rabeprazole (AcipHex®), Pantoprazole (Protonix®), Dexlansoprazole (Dexilant®) and omeprazole with sodium bicarbonate (Zegerid®). PPIs allow rapid relief of symptoms and healing of the esophagus in 80–90% of patients. To be most effective, PPIs should be taken on a fasting stomach, 30-60 minutes before a meal. They can also be used to potentially reduce the cancer risk in patients with Barrett’s esophagus, according to gastroenterology society guidelines.
Risk of PPIs?
PPIs have long been considered a safe class of drugs; however, over the last decade multiple small studies historically raised concerns about chronic use of PPIs. Those studies reported different side effects, such as osteoporosis, heart disease, pneumonia, enteric infections, dementia, kidney disease, and nutritional deficiencies. Newer better-quality studies were not able to substantiate those claims. An online survey of GERD patients using PPIs showed that 46% were somewhat/extremely concerned about PPI safety, and 36% had attempted to stop PPI without provider recommendation. Ultimately, patients should ask their doctor whether they need PPIs. Some reasons include: such as for history of erosive esophagitis, Barrett’s esophagus, or confirmed, poorly controlled GERD, eosinophilic esophagitis, or history of gastrointestinal bleeding while on blood thinners. For patients with a history of esophagitis, stricture, or Barrett’s esophagus, long-term PPI use is helpful to prevent further complications of GERD even if symptoms are well controlled.
Potassium competitive acid blockers (PCABs)
Potassium competitive acid blockers (PCABs) reduce the amount of acid produced in the stomach, can help with symptoms, and are stronger than H2 blockers. Vonoprazan (Voquezna®) is the first drug in this class of medications. PCABs allow rapid relief of symptoms and healing of the esophagus in 80–90% of patients. Unlike PPIs, PCABs do not have to be taken 30-60 minutes before a meal. For patients with a history of esophagitis, long-term PCAB use is helpful to prevent further complications of GERD even if symptoms are well controlled.
Promotility agents
Promotility agents speed up stomach emptying. This helps improve LES pressure which improves the clearance of acid from the esophagus. The most widely studied promotility agents for the treatment of GERD are: bethanechol (Urecholine®), metoclopramide (Metozolv® ODT and Reglan®), domperidone (Motilium®, Nauzelin®, Domstal® and others) and cisapride (Prepulsid®). Promotility agents can be helpful for some people with non-erosive GERD or mild esophagitis. Use of this drug; however, should be decided after careful screening for known risk factors as there are many reported adverse effects with these medications. You should have a thorough discussion with your healthcare provider about these before beginning treatment.
Functional heartburn
Many patients have heartburn that does not respond to GERD treatments. Other patients have heartburn but do not have GERD. Functional heartburn is a common and unrecognized cause of bothersome heartburn in both cases that is caused by abnormal nerve sensation and can be treated with off-label antidepressants. Such drugs are commonly used by primary care providers outside of gastroenterology for patients with diabetes and other conditions that affect nerve sensation. Prescription and monitoring of off label antidepressants for functional heartburn should be monitored ideally by the primary care provider once GERD is either identified and treated appropriately or ruled out.
Healthy weight loss
Obesity is a common cause of acid reflux because central abdominal fat causes enough pressure to push acid into the esophagus. Healthy weight loss, while maintaining lean muscle body mass to sustain the basal metabolic rate, can play an important role in resolving GERD as a primary form of treatment. Patients that achieve and maintain successful weight loss but have a history of esophagitis, stricture, or Barrett’s esophagus still benefit from long-term PPI therapy.
Summary
Even after symptoms are brought under control, the underlying disease remains present. It is possible that a person may need to take medication for the rest of their life to manage GERD. Long-term use of medication – whether prescription or nonprescription – should be under the direction and supervision of a physician. Side effects are rare; nonetheless, any drug can potentially have adverse effects.
Read more about long-term GERD treatments
Read more questions and answers about medications and GERD
Adapted from IFFGD Publication: Medications for the Treatment of Gastroesophageal reflux disease (GERD) by Eric Shah, M.D., M.B.A., FACG; Clinical Associate Professor; Medical technology and innovation; University of Michigan
