Proton pump inhibitors in gastro-oesophageal reflux disease

• acid suppression is the basis of treatment for GORD, and can be achieved effectively with proton pump inhibitors (PPIs) (1)
• some of the PPIs available include-omeprazole, lansoprazole, rabeprazole, pantoprazole, and esomeprazole (1)
• they should be taken before meals
  • generally before breakfast if taken once daily (1)
• a healing dose of a proton pump inhibitor (PPI) should be prescribed in patients with severe symptoms of gastro-oesophageal reflux disorder (GORD) or who have proven pathology (2) (oesophageal ulceration or Barrett's oesophagus)
• after symptomatic control has been achieved then the dose should be reduced to the lowest dose that allows symptomatic control
• the higher healing dose should be recommenced if there is a recurrence of GORD symptoms
• in cases of complicated oesophagitis (e.g. haemorrhage, stricture) the the higher healing dose should be maintained
• in patients who do not have proven pathology/mild symptoms of GORD then often alternative therapies to PPIs can be used in management e.g. alginates, antacids, H2 receptor antagonists
• in severe cases a H2-antagonist may be used in addition
• in some patients, gastric motility stimulants may be effective, by increasing the rate of gastric emptying and hence, reducing the opportunity for reflux. Metoclopramide and domperidone, may be of use in stimulation of gastric emptying, particularly in patients with systemic sclerosis, diabetes mellitus, and autonomic neuropathy. Cisapride has been withdrawn from marketing in the UK (3)
• since GORD is a chronic condition, continuous, even lifelong, therapy may be necessary (1)
  • on-demand versus continuous maintenance therapy with a PPI:
    • there is evidence from a systematic review that on-demand maintenance therapy with a PPI is more effective than placbo for controlling symptoms. Also on-demand PPI therapy is as effective as continuous PPI therapy in patients with non-erosive GORD but not those with more severe disease (4)

Note:

• treatment of reflux oesophagitis with omeprazole in patients who are H. pylori positive increases the risk of atrophic gastritis (5)

Reference:

• (1) Kenneth R., et al.Updated guidelines for the diagnosis and treatment of Gastroesophageal reflux disease. American journal of gastroenterology 2005;100:190-200
• (2) NICE (July 2000). Guidance on the use of proton pump inhibitors in the treatment of dyspepsia.
• (3) Committee on Safety of Medicines (July 2000).Suspension of cisapride (Prepulsid): Product withdrawal.
• (4) Pace F et al. Systematic review: maintenance treatment of gastro-oesophageal reflux disease with proton pump inhibitors taken 'on-demand'.Aliment Pharmacol Ther 2007;26:195-204.
• (5) Kuipers, EJ. et al. (1996). Atrophic gastritis and Helicobacter pylori infection in patients with reflux esophagitis treated with omeprazole or fundoplication. New Engl. J. Med.; 334: 1018-22.
• (6) Drug and Therapeutics Bulletin (1996); 34 (1): 1-4.