Gastroesophageal reflux disease, drugs used in GERD, side effects and MCQs for GPAT, NIPER, Drug inspector and pharmacist exam.

GERD: Gastroesophageal reflux disease, it is a digestive disease in which stomach acid or bile irritates the food pipe lining. This is a chronic disease in which stomach acid and bile flows into the food pipe and irritates the lining. Acid reflux and heartburn more than twice a week may indicates GERD.

Risk factors: Smoking, eating large meals, eating late at night, drinking certain beverages such as alcohol and coffee, eating certain foods (triggers) such as fatty or fried foods and taking certain medications such as aspirin.

Sign and symptom: GERD have three stages of sign and symptom.

1. Stage1: <3 episodes/week , mild symptoms with occasional heartburn and no esophageal lesions.

2. Stage2: >3 episodes/week of moderately severe symptoms, nocturnal awakening due to regurgitation and esophagitis may be present or not.

3. Stage3: Daily and chronic symptoms, esophagitis, disturb sleep, laryngitis, hoarseness, dry cough and asthma. Symptoms reoccur after treatment is stopped.

Different classes of drugs in GERD are used: 

A. Proton pump inhibitors: These are the most effective drugs for healing of esophageal lesions, symptomatic relief  and prevention of complications. Proton pump inhibitors (PPIs) block the gastric H,K-ATPase, inhibiting gastric acid secretion. This effect enables healing of peptic ulcers, gastroesophageal reflux disease (GERD), barrett’s esophagus, and Zollinger-Ellison syndrome, as well as the eradication of Helicobacter pylori as part of combination regimens. PPIs also help prevent heartburn, the burning sensation that often accompanies GERD. Example of proton pump inhibitors are:

1. Omeprazole
2. Esomeprazole
3. Lansoprazole
4. Iiaprazole
5. Pantoprazole

 Side effects: Accelerated osteoporosis among elderly patients has been associated with high dose long term use of PPIs for GERD. Chronic PPI therapy cause increase in infection.

B. H2 blockers: H2 blockers compete with histamine for H2 receptors on the stomach’s parietal cells and thereby depress the production of HCL. They cause less compete acid suppression than PPIs. Adequate symptom relief is obtained only in mild cases, healing of esophagitis may occur in 50-70% patients. H2 antagonist  are indicated for ‘on demand symptoms’ relief when symptoms are occasional or stage 1 symptoms of GERD. Symptoms relief occurs 30-60min after drug intake and lasts upto 8 hrs. Drugs of H2 blockers used in GERD:

1. Cimetidine
2. Famotidine
3. Nizatidine
4. Rantidine

Side effects: Constipation, diarrhea, difficulty in sleeping, dry skin, dry mouth, ringing in ears and a runny nose.

C. Antacids: The use of antacid are limited for occasional, intercurrent relief of heartburn, because they act in minutes, but relief may last only 2-3hrs. Antacids are quick relief methods that work by directly counteracting the acidity inside your stomach. The presence of these acids is natural in the stomach because they work to help digest food. Antacids only neutralize acid and don’t treat the inflammation caused by GERD. Drugs used in GERD:

1. Aluminum hydroxide gel
2. Calcium carbonate
3. Magnesium hydroxide

Side effects: 

1. Gas or belching.
2. Swelling in the feet, ankles, and hands
3. Constipation (products containing calcium or aluminum)
4. Diarrhea (products containing magnesium)

Drug interactions: Antacids may interfere with these drugs,  such as levothyroxine or the blood thinner warfarin.

D. Sodium alginate:  Sodium alginate reacts with gastric acid to form a floating “raft” of alginic acid gel on the gastric acid pool. Alginate-based raft-forming formulations commonly contain sodium or bicarbonate; bicarbonate ions are converted to carbon dioxide in presence of gastric acid and get entrapped within the gel precipitate, converting it into a foam which floats on the surface of the gastric contents, much like a raft on water and may prevent contact of acid with esophageal mucosa. It has no effect on LES tone.

Side effects: clinical symptoms, which were vomiting and weight gain after the treatment. No side effect except thickening of stool in 3 patients was observed.

E. Prokinetic drugs: These drugs ( Metoclopramide, mosapride and other prokinetic drugs) may relieve regurgitation and heartburn by increasing LES tone, improving esophageal clearance and facilitating gastric emptying  but don not effect gastric acidity or promote healing of esophagitis. Symptom control afforded by prokinetic drugs is much inferior to that of PPIs/H2 blocker . Their use in GERD is declined.

MCQs:

1. A condition where stomach contents flow back (reflux) into the esophagus (food tube) causing troublesome symptoms and possible damage to the esophagus.

a. GERD

b. Peptic ulcer

c. Ulcerative colitis

d. None

2. What are the risk factors of GERD?

a. Smoking

b. Eating large meals

c. Eating fried food

d. All of above

3. What are the sign and symptoms of GERD?

a. Hoarseness

b. Disturb sleep

c. Esophagitis

d. All of above

4. Chronic PPI therapy cause?

a. Stomach ulcer

b. Allergic reactions

c. Increase in infection

d. None

5. What is the role of PPI in GERD?

a. Increase gastric acid secretion

b. Healing of esophageal lesions

c. Increase nocturnal awakening

d. Increase infection

6. What are the side effects of H2blockers?

a. Ringing in ears

b. Dry mouth

c. Constipation

d. All of above

7. What is GERD?

a. Stomach acid or bile irritates the food pipe lining.

b. Acid reflux

c. Heart burn

d. All of above

8. Proton pump inhibitors used in GERD?

a. Omeprazole

b. Sodium bicarbonate

c. Aluminum hydroxide gel

d. Cimetidine

9. Antacids used in GERD?

a. Aluminum hydroxide gel

b. Calcium carbonate

c. Magnesium hydroxide

d. All of above

10. What are the adverse effects of antacids?

a. Blenching

b. Constipation

c. a$b

d. None

11. Which drug is reacts with gastric acid to form a floating “raft” of alginic acid gel on the gastric acid pool. 

a. Pantoprazole

b. Sodium alginate

c. Cimetidine

d. Aluminum hydroxide gel

12. Which H2 blocker used in GERD?

a. Cimetidine

b. Pantoprazole

c. Sodium alginate

d. None

  13. Accelerated osteoporosis among elderly patients has been associated with ?

a. PPI

b. H2 blockers

c. Sodium alginate

d. Prokinetic drug

14. Which drug in GERD facilitate gastric emptying?

a. Prokinetic drug

b. PPI

c. Sodium alginate

d. None

15. Occasional heartburn and no esophageal lesions symptom of which stage?

a. Stage I

b. Stage II

c. Stage III

d. All of above.

Answers:

1. a
2. d
3. d
4. c
5. b
6. d
7. d
8. a
9. d
10. c
11. b
12. a
13. a
14. a
15. a

References:

1. “K.D. Tripathi” Peptic ulcer and GERD , page no: 707-708, 8th edition 2018.
2. “Tyler Walker” H2 receptor blocker, April9, 2020.
3. “Frieda Wiley” Rosalsn Carson Dewit Everyday health, oct 19, 2015.

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