Medications to control GERD symptoms: Pros and Cons
Acid Reducing Medications Control Heartburn When Used Appropriately.
In mild GERD (Stage 1), heartburn occurs rarely and sometimes predictably with a known trigger meal or food. In these patients, acid neutralizers used intermittently whenever heartburn occurs or to prevent heartburn when a person knows by experience that the meal they are going to eat has a high chance of precipitating heartburn is adequate to maintain a good quality of life.
Learn more: The progressive stages of GERD
In patients with moderate GERD (Stage 2) where damage to the LES is greater and heartburn is more frequent and less predictable, it becomes increasingly difficult to control symptoms adequately with a simple acid neutralizer taken on demand. An acid suppressive drug becomes necessary. The addition of an H2 receptor antagonist, used in the short term to supplement the neutralizer or used alone, is often effective in controlling symptoms and allowing injuries to the lining of the esophagus to heal.
As GERD severity increases (to Stage 3), heartburn occurs frequently and without predictability. Intermittent use of acid neutralizers and H2 receptor antagonists no longer provide adequate symptom control to maintain a reasonable quality of life. For these patients, long term acid suppressive treatment is necessary, usually with the strongest agents, the PPIs. PPIs are very effective in controlling heartburn in the long term, but do not act immediately (like the acid neutralizers) or quickly (like the H2 receptor antagonists). It takes up to 48 hours for PPIs to block the acid secreting mechanism in the stomach cells.
Suppression Of Acid Limits Damage That Occurs During Reflux.
Less acidic refluxed material injures the esophagus less than more acidic refluxed material. Erosions do not occur with the same frequency as long as the drug is taken in sufficient dosage to control acid throughout the day.
Acid Suppressive Drugs Allow Injury To The Lining Of The Esophagus To Heal.
If erosions are present, these drugs allow them to heal. Because a patient with acute erosions is more likely to have pain during reflux, healing of erosions can make a short course (e.g. two weeks) of acid suppressive drug treatment effective in healing erosions and decreasing the probability of pain when reflux occurs. Acid neutralizers are less effective in healing erosions. Because erosions usually signify more severe reflux disease, PPIs are the most reliable acid suppressive agents if the objective is to heal erosions.
Acid Suppressive Drugs Decrease The Frequency Of Long-Term Injury To The Lining Of The Esophagus.
Because acid suppressive drugs limit injury to the lining of the esophagus, long-term complications of GERD occur less frequently when these drugs are used on a long-term basis. In the past, severe and chronic ulcers of the esophagus resulted from reflux and sometimes led to severe bleeding and even perforation of the esophagus. Scarring associated with injury resulted in strictures, which are areas of narrowing of the esophagus that can make swallowing difficult. These injury-associated complications have decreased in patients with GERD over the past 40 years, a testament to the effectiveness of these drugs in controlling acid-induced injury.
Acid Suppressive Drugs Do Not Address The Cause Of GERD.
LES damage, which is the basic cause of GERD, is permanent and not reversed by any of these drugs, even the most powerful PPIs used at maximum dosage for a long time.
Learn more: GERD explained: The role of the LES
Reflux Episodes Continue To Occur In Patients Who Are Taking Acid Suppressive Medications.
Neither the number nor duration of reflux episodes is decreased by use of these drugs, even in maximum dosage. As such, the lining of the esophagus continues to be exposed to all the contents of gastric juice except acid.
The Symptom Of Regurgitation Is Usually Not Well Controlled By Suppression Of Acid With Drugs.
Regurgitation commonly signifies severe LES damage and is not prevented by medications. Because reflux episodes are not decreased by these drugs, if a person feels the reflux into their esophagus or mouth, this will likely continue. The taste of material entering the mouth may be less acidic and different.
Learn more: Regurgitation: A sign of advancing reflux disease
Acid Suppressive Drugs Do Not Prevent The Complications Associated With Columnar Epithelium In The Esophagus.
Normally the esophagus is lined with squamous epithelium. When squamous epithelium is injured by reflux, it frequently undergoes transformation (metaplasia) into a different type of epithelium known as columnar epithelium. This columnar epithelium is more resistant to acid-induced damage and less pain sensitive that squamous epithelium. The initial columnar epithelium that forms is benign and not associated with cancer risk. However, in some patients, a second change, known as intestinal metaplasia, occurs in the columnar epithelium. This is Barrett’s esophagus, which has an increased risk of cancer.
These cellular changes are the result of molecules in the refluxed gastric juice bombarding the esophagus. Even when symptoms are well controlled by acid suppressive drugs, these molecules continue their assault on the lining of the esophagus. As a result, Barrett’s esophagus and cancer can occur even in a patient with symptoms that controlled by acid suppressive medications. In fact, recent studies have shown that cancer is more common in patients who are on long-term continuous PPI therapy (compared to intermittent use or no PPIs) and in patients whose symptoms are well controlled (rather than poorly controlled).
Over the past four decades, while PPIs have dramatically reduced injury-associated changes such as ulcers and strictures, the incidence of Barrett’s esophagus and esophageal cancer have dramatically increased. This begs the question as to whether acid suppression, while beneficial to the squamous lining of the esophagus, has a negative effect on the GERD-induced columnar epithelium, driving it to Barrett’s esophagus and cancer. In my opinion, the medical community has not performed the studies necessary to address this critical question seriously.
Learn more: Inside your esophagus: The damage caused by GERD
All Acid Suppressive Drugs Have Side Effects.
These side effects are not significant when the drugs are acid neutralizers or when stronger drugs are used intermittently. However, when PPIs are used long term and on a continuous basis, there are significant side effects. These are largely based on the fact that normal gastric acid has been suppressed. All the normal functions that acid performs in gastric juice can be expected to decrease. These normal functions include facilitating absorption of some food items and acting as an antibacterial barrier. Some of the complications associated with long-term use of PPIs are:
- Malabsorption of calcium with an increased likelihood of osteoporosis and bone (notably hip) fractures.
- Malabsorption of magnesium with effects caused by decreased magnesium levels in the blood.
- Increased incidence of infections of the intestines, notably a serious infection known as Clostridium difficile colitis.
- Increased incidence of pneumonia.
- Long-term PPI use is also known to have adverse interactions with other drugs, notably Plavix, whose effectiveness is significantly decreased in patients who are on long-term PPIs. Unless recognized these drug interactions can lead to serious complications.
Always use medications appropriately.
The use of acid suppressive drugs should be regarded as relatively innocuous if acid neutralizers are used or when any drug is used intermittently (i.e. used for no longer than two weeks). When PPIs are used in the longer term, care must be exercised to ensure that the positives (controlling symptoms, healing and preventing injury) outweigh the negatives (significant side effects, the failure to prevent Barrett’s esophagus and cancer, and cost). The use of these powerful drugs should be carefully assessed and considered with full knowledge of what they do and do not do.