What drugs can be prescribed to reduce gastric acid secretion for gastric reflux conditions?

Prescription esomeprazole comes as a delayed-release (releases the medication in the intestine to prevent break-down of the medication by stomach acids) capsule to take by mouth or to open, mix with water, and give through a feeding tube, and as packets of delayed-release (releases the medication in the intestine to prevent break-down of the medication by stomach acids) granules for suspension (to be mixed with water) to take by mouth or give through a feeding tube. Nonprescription (over-the-counter) esomeprazole comes as a delayed-release capsule and tablet to take by mouth. Prescription esomeprazole is usually taken once a day at least 1 hour before a meal. When prescription esomeprazole is used to treat certain conditions in which the stomach makes too much acid, it is taken twice a day. The nonprescription delayed-release capsules and tablets are usually taken once a day in the morning at least 1 hour before eating for 14 days in a row. If needed, additional 14-day treatments may be repeated, not more often than once every 4 months.

Table of Contents Show

Treatment Approaches for GERD
GERD Treatment: Lifestyle and Dietary Changes
GERD Treatment: Medication
TIF and Other Endoscopic Therapy
Extra-esophageal Manifestations

Take esomeprazole at around the same time(s) every day. Follow the directions on your prescription label carefully, and ask your doctor or pharmacist to explain any part you do not understand. Take esomeprazole exactly as directed. Do not take more or less of it or take it more often than or for a longer period of time than prescribed by your doctor or stated on the package.

Swallow the capsules whole; do not split, chew, or crush them. If you cannot swallow the capsule, put 1 tablespoon of cool, soft applesauce in an empty bowl. Open one esomeprazole capsule and carefully sprinkle the pellets onto the applesauce. Mix the pellets with the applesauce and swallow the entire tablespoonful of the applesauce and pellet mixture immediately. Do not crush or chew the pellets in the applesauce. Do not save the pellets and applesauce for later use.

If you are taking the granules for oral suspension, you will need to mix it with water before use. If you are using the 2.5- or 5-mg packet, place 1 teaspoonful (5 mL) of water in a container. If you are using the 10-, 20-, or 40-mg packet, place 1 tablespoonful (15 mL) of water in a container. Add the contents of the powder packet and stir. Wait 2 to 3 minutes to allow the mixture to thicken, and stir the mixture again. Drink the entire mixture within 30 minutes. If any of the mixture is stuck to the container, pour more water into the container, stir and drink all the mixture immediately.

The granules and the contents of the prescription delayed-release capsules can both be given through a feeding tube. If you have a feeding tube, ask your doctor or pharmacist how you should take the medication. Follow those directions carefully.

Do not take nonprescription esomeprazole for immediate relief of heartburn symptoms. It may take 1 to 4 days for you to feel the full benefit of the medication. Call your doctor if your symptoms get worse or do not improve after 14 days or if your symptoms return sooner than 4 months after you finish your treatment. Do not take nonprescription esomeprazole for longer than 14 days or treat yourself with esomeprazole more often than once every 4 months without talking to your doctor.

Continue to take prescription esomeprazole, even if you feel well. Call your doctor if your symptoms worsen or do not improve during this time. Do not stop taking esomeprazole without talking to your doctor.

Ask your pharmacist or doctor for a copy of the manufacturer's information for the patient.

Gastroenterology Gastric Surgery

There are four approaches for gastroesophageal reflux disease (GERD) treatment, including medication and surgery. Often, patients respond well to a combination of lifestyle changes and a medication regimen.

Some patients do not find satisfactory relief from those methods and require surgical intervention. Other patients may choose surgery as an alternative to a lifetime of taking medication.

Treatment Approaches for GERD

Lifestyle and dietary changes
Medication
Endoscopic therapy
Surgery

GERD Treatment: Lifestyle and Dietary Changes

Dietary and lifestyle changes are the first step in treating GERD. Certain foods make the reflux worse. Suggestions to help alleviate symptoms include:

Lose weight if you are overweight — of all of the lifestyle changes you can make, this one is the most effective.
Avoid foods that increase the level of acid in your stomach, including caffeinated beverages.
Avoid foods that decrease the pressure in the lower esophagus, such as fatty foods, alcohol and peppermint.
Avoid foods that affect peristalsis (the muscle movements in your digestive tract), such as coffee, alcohol and acidic liquids.
Avoid foods that slow gastric emptying, including fatty foods.
Avoid large meals.
Quit smoking.
Do not lie down immediately after a meal.
Elevate the level of your head when you lie down.

GERD Treatment: Medication

If lifestyle and dietary changes do not work, your doctor may prescribe certain medications. There are two categories of medicines for reflux. One decreases the level of acid in your stomach, and one increases the level of motility (movement) in the upper gastrointestinal tract.

Antacids

Over-the-counter antacids are best for intermittent and relatively infrequent symptoms of reflux. When taken frequently, antacids may worsen the problem. They leave the stomach quickly, and your stomach actually increases acid production as a result.

Histamine blockers

Histamine 2 (H2) blockers are drugs that help lower acid secretion. H2 blockers heal esophageal erosions in about 50 percent of patients.

Proton pump inhibitors

Proton pump inhibitors (PPIs) are drugs that block the three major pathways for acid production. PPIs suppress acid production much more effectively than H2 blockers. PPIs heal erosive esophagitis in many patients, even those with severe esophageal damage.

Prokinetic agents

Prokinetic agents are drugs that enhance the activity of the smooth muscle of your gastrointestinal tract. These drugs are somewhat less effective than PPIs. Your doctor may prescribe them in combination with an acid-suppressing drug.

TIF and Other Endoscopic Therapy

Transoral incisionless fundoplication (TIF) is an option to address GERD. TIF can mean a shorter treatment time, less pain and faster recovery compared to laparoscopic surgery. The procedure involves using a special TIF device to create a passageway for a flexible, tube-like imaging instrument called an endoscope. The procedure allows the physician to use preloaded tweezers and fasteners to repair or recreate the valve that serves as a natural barrier to reflux.

Currently, there are clinical trials testing the efficacy of endoscopic therapy for GERD. One form of therapy uses an endoscopic sewing machine to place sutures in the stomach and increase the anti-reflux barrier.

If your symptoms did not improve with lifestyle changes or drug therapy, you may be a candidate for surgery. Some patients prefer a surgical approach as an alternative to a lifetime of taking medications. The goal of surgery for reflux disease is to strengthen the anti-reflux barrier.

During a procedure known as a Nissen fundoplication, your surgeon wraps the upper part of your stomach around the lower esophagus. This enhances the anti-reflux barrier and can provide permanent relief from reflux. Your surgeon may perform this surgery laparoscopically, which means a less invasive procedure with a shorter recovery time.

Extra-esophageal Manifestations

Reflux may affect more than just the esophagus. Reflux can lead to inflammation of the pharynx (part of the throat right behind the mouth) and larynx (voice box). It may also cause bronchitis, asthma or pneumonia. If there are no obvious causes for the inflammation, your doctor may suspect reflux. The goal of treatment is to improve the symptoms through medication.

1. Khan K: Pharmacologic treatment of hypersecretory disorders. Resident Reporter 2000; 5:23–28 [Google Scholar]

2. Wolfe MM, Sachs G: Acid suppression: Optimizing therapy for gastroduodenal healing, gastroesophageal reflux disease, and stress-related erosive syndrome. Gastroenterology 2000; 118:S9–S31 [PubMed] [Google Scholar]

3. Robertson D, Alders M, Shepherd H, et al.: Patterns of acid reflux in complicated esophagitis. Gut 1987; 28:1484–1488 [PMC free article] [PubMed] [Google Scholar]

4. Hatlebakk JG, Katz PO, Kuo B, et al.: Nocturnal gastric acidity and acid breakthrough on different regimens of omeprazole 40 mg daily. Aliment Pharmacol Ther 1998; 12: 1235–1240 [PubMed] [Google Scholar]

5. Katz PO, Anderson C, Khoury R, et al.: Gastro-oesophageal reflux associated with nocturnal gastric acid breakthrough on proton pump inhibitors. Aliment Pharmacol Ther 1998; 12:1231–1234 [PubMed] [Google Scholar]

6. Modlin IM, Sachs G: Acid Related Disease: Biology and Treatment: Section 2. The Regulation of Gastric Acid Secretion Konstanz, Germany, Schnetztor Verlag, 1998 [Google Scholar]

7. Zeng N, Athmann C, Kang T, et al.: PACAP type I receptor activation regulates ECL cells and gastric acid secretion. J Clin Invest 1999; 104:1383–1391 [PMC free article] [PubMed] [Google Scholar]

8. Pisegna JR, Wank SA: Molecular cloning and functional expression of the pituitary adenylate cyclase-activating polypeptide type I receptor. Proc Natl Acad Sci U S A 1993; 90: 6345–6349 [PMC free article] [PubMed] [Google Scholar]

9. Wolfe MM, Soll AH: The physiology of gastric acid secretion. N Engl J Med 1988; 319: 1707–1715 [PubMed] [Google Scholar]

10. Prinz C, Kajimura M, Scott DR, et al.: Histamine secretion from rat enterochromaffin-like cells. Gastroenterology 1993; 105: 449–461 [PubMed] [Google Scholar]

11. Waldum HL, Sandvik AK, Syversen U, et al.: The enterochromaffin-like (ECL) cell: Physiological and pathophysiological role. Acta Oncol 1993; 32:141–147 [PubMed] [Google Scholar]

12. Ray JM, Squires PE, Curtis SB, et al.: Expression of the calcium-sensing receptor on human antral gastrin cells in culture. J Clin Invest 1997; 99:2328–2333 [PMC free article] [PubMed] [Google Scholar]

13. Cheng I, Qureshi I, Chattopadhyay N, et al.: Expression of an extracellular calciumsensing receptor in rat stomach. Gastroenterology 1999; 116:118–126 [PubMed] [Google Scholar]

14. Mitsuma T, Rhue N, Kayama M, et al.: Distribution of calcium sensing receptor in rats: An immunohistochemical study. Endocr Regul 1999; 33:55–59 [PubMed] [Google Scholar]

15. Meichsner CL, Lee FP, Hobson SA, et al.: Identification of a functional Ca2+-sensing receptor in normal human gastric mucous epithelial cells. Am J Physiol 1999; 277(3 Pt 1):G662. [PubMed] [Google Scholar]

16. York MR: Proton pump inhibitors: An overview. Resident Reporter 1999; 4:15–20 [Google Scholar]

17. Boyce HW: Therapeutic approaches to healing esophagitis. Am J Gastroenterol 1997; 92:23S–29S [PubMed] [Google Scholar]

18. Jungnickel PW: Pantoprazole: A new proton pump inhibitor. Clin Ther 2000; 22: 1268–1293 [PubMed] [Google Scholar]

19. Protonix IV (pantoprazole sodium) package insert Philadelphia, Wyeth Laboratories, 2001 [Google Scholar]

20. Meyer UA: Interaction of proton pump inhibitors with cytochrome P450: Consequences for drug interaction. Yale J Biol Med 1996; 69:203–209 [PMC free article] [PubMed] [Google Scholar]

21. Meyer UA: Metabolic interactions of the proton-pump inhibitors lansoprazole, omeprazole, and pantoprazole with other drugs. Eur J Gastroenterol Hepatol 1996; 8(Suppl 1): S21–S25 [PubMed] [Google Scholar]

22. Parsons ME: Pantoprazole, a new protonpump inhibitor, has a precise and predictable profile of activity. Eur J Gastroenterol Hepatol 1996; 8(Suppl 1):S15–S20 [PubMed] [Google Scholar]

23. Ahmed T: Update on treatment of stress-related bleeding in critically ill patients. Resident Reporter 2000; 5:71–75 [Google Scholar]

24. Brunner G, Luna P, Thiesemann C: Drugs for pH control in upper gastrointestinal bleeding. Aliment Pharmacol Ther 1995; 9(Suppl 1):47–50 [PubMed] [Google Scholar]

25. Merki HS, Wilder-Smith CH: Do continuous omeprazole and ranitidine retain their effect with prolonged dosing. Gastroenterology 1994; 106:60–64 [PubMed] [Google Scholar]

26. Sharma VK, Heinzelmann EJ, Steinberg EN, et al.: Nonencapsulated, intact omeprazole granules effectively suppress intragastric acidity when administered via a gastrostomy. Am J Gastroenterol 1997; 92:848–851 [PubMed] [Google Scholar]

27. Sharma VK, Vasudeva R, Howden CW: Simplified lansoprazole suspension—a liquid formulation of lansoprazole— effectively suppress intragastric acidity when administered through a gastrostomy. Am J Gastroenterol 1999; 94:1813–1817 [PubMed] [Google Scholar]

28. Sharma VK, Vasudeva R, Howden CW: The effects on intragastric acidity of per-gastrostomy administration of an alkaline suspension of omeprazole. Aliment Pharmacol Ther 1999; 13:1091–1095 [PubMed] [Google Scholar]

29. Sharma VK: Comparison of 24-hour intragastric pH using four liquid formulations of lansoprazole and omeprazole. Am J Health Syst Pharm 2000; 57:699 [PubMed] [Google Scholar]

30. Sharma VK, Peyton B, Spears T, et al.: Oral pharmacokinetics of omeprazole and lansoprazole after single and repeated doses as intact capsules or as suspensions in sodium bicarbonate. Aliment Pharmacol Ther 2000; 14:887–892 [PubMed] [Google Scholar]

31. Lasky MR, Metzler MH, Phillips JO: A prospective study of omeprazole suspension to prevent clinically significant gastrointestinal bleeding from stress ulcers in mechanically ventilated trauma patients. J Trauma 1998; 44:527–533 [PubMed] [Google Scholar]

32. Levy MJ, Seelig CB, Robinson NJ, et al.: Comparison of omeprazole and ranitidine for stress ulcer prophylaxis. Dig Dis Sci 1997; 42:1255–1259 [PubMed] [Google Scholar]

33. Cook DJ, Fuller HD, Guyatt GH, et al.: Risk factors for gastrointestinal bleeding in critically ill patients: Canadian Critical Care Trials Group. N Engl J Med 1994; 330:377–381 [PubMed] [Google Scholar]

34. Cook D, Guyatt G, Marshall J, et al.: A comparison of sucralfate and ranitidine for the prevention of upper gastrointestinal bleeding in patients requiring mechanical ventilation: Canadian Critical Care Trials Group. N Engl J Med 1998; 338:791–797 [PubMed] [Google Scholar]

35. Balaban DH, Duckworth CW, Peura DA: Nasogastric omeprazole: Effects on gastric pH in critically ill patients. Am J Gastroenterol 1997; 92:79–83 [PubMed] [Google Scholar]

36. Dunn A, White CM, Reddy P, et al.: Delivery of omeprazole and lansoprazole granules through a nasogastric tube in vitro. Am J Health Syst Pharm 1999; 56: 2327–2330 [PubMed] [Google Scholar]

37. Fennerty MB: Pathophysiology of the upper gastrointestinal tract in the critically ill patient: Rationale for therapeutic benefits of acid suppression. Crit Care Med 2002; 30: S351–S355 [PubMed] [Google Scholar]

38. Younes Z: Medical therapies for bleeding peptic ulcer. Resident Reporter 1999; 4:52–56 [Google Scholar]

39. Manzionna G, Pace F, Bianchi Porro G: Efficacy of lansoprazole in the short- and longterm treatment of gastro-oesophageal reflux disease: A systematic overview. Clin Drug Invest 1997; 6:450–456 [Google Scholar]

40. Hetzel DJ, Dent J, Reed WD, et al.: Healing and relapse of severe peptic esophagitis after treatment with omeprazole. Gastroenterology 1998; 95:903–912 [PubMed] [Google Scholar]

41. Metz DC, Pratha V, Martin P, et al.: Oral and intravenous dosage forms of pantoprazole are equivalent in their ability to suppress gastric acid secretion in patients with gastroesophageal reflux disease. Am J Gastroenterol 2000; 95:626–633 [PubMed] [Google Scholar]

42. Pisegna JR: The effect of Zollinger-Ellison syndrome and neuropeptide secreting tumors on the stomach. Curr Gastroenterol Rep 1999; 1:511–517 [PubMed] [Google Scholar]

43. Metz DC, Benya RV, Fishbeyn VA, et al.: Prospective study of the need for long-term antisecretory therapy in patients with Zollinger-Ellison syndrome following successful curative gastrinoma resection. Aliment Pharmacol Ther 1993; 7:247–257 [PMC free article] [PubMed] [Google Scholar]

44. Lew EA, Pisegna JR, Starr JA, et al.: Intravenous pantoprazole rapidly controls gastric acid hypersecretion in patients with Zollinger–Ellison syndrome. Gastroenterology 2000; 118:696–704 [PMC free article] [PubMed] [Google Scholar]

45. Metz DC, Forsmark CE, Lew EA, et al.: Replacement of oral proton pump inhibitors with intravenous pantoprazole effectively maintains control of gastric acid hypersecretion in patients with Zollinger-Ellison syndrome (ZES). Am J Gastroenterol 2001; 96: 3274–3280 [PubMed] [Google Scholar]

46. Dubois A: Control of gastric acid secretion, Chapter 20. In: Clinical Practice of Gastroenterology Vol. 1 Brandt LJ (Ed). Philadelphia, Churchill Livingstone, 1999, pp 180–188 [Google Scholar]

47. Aris R, Karlstadt R, Paoletti V, et al.: Intermittent intravenous pantoprazole achieves a similar onset time to pH Š 4.0 in ICU patients as continuous infusion H2-receptor antagonist, without tolerance. Abstr. Am J Gastroenterol 2001; 96:S48 [Google Scholar]