Gastroesophageal reflux disease (GERD)--also known as heartburn--plagues millions of Americans each year. It's often a chronic condition that presents with recurring symptoms of burning chest pain, regurgitation, asthma-like symptoms and cough. Patients diagnosed with GERD may be placed on lifelong medication based on severity and cause of disease. There is always concern regarding side effects of prolonged use when taking any medication for the long term.
Acid Neutralizers (Antacids)
Antacids are the most common and widely used drugs for reflux. Over-the-counter drugs, calcium carbonate and magnesium hydroxide are two acid neutralizers used for mild symptoms of acid reflux disease. These agents raise the pH of stomach acid, decreasing acidity and potential for damaging the esophagus. Used sparingly, these drugs pose little problems. Used in large quantities over long periods can lead to hypercalcemia, renal stones and metabolic alkalosis. Esteemed professor of renal diseases Eduardo Slatopolsky showed that many of the long-term effects can be controlled under the right conditions.
Mucosal Barriers
By attaching to inflamed damaged tissue, mucosal barriers protect the lining of the esophagus and stomach from further harm, assisting in the acceleration of the healing process. One commonly used barrier drug is sucralfate, which is used in a limited fashion. In 1991, an isolated study revealed concerns regarding long-term accumulation of aluminum in serum. However, a more recent study by Kinoshita and colleagues indicate that there is no appreciable measurement of aluminum in urine or serum.
Acid Suppressive Agents
Both histamine blockers and proton pump inhibitors suppress the production of hydrochloric acid in the stomach.
Histamine blockers inhibit histamine receptors, reducing acid production. A few commonly used histamine blockers are ranitidine, cimetidine and famotidine. These can be found at any drug store. The long-term concern with long periods of use is the paradoxical effect of a decrease in mucosal barrier production, according to Miyake K. in a study done on rats. Tolerance is also of concern with repeated large doses of histamine blockers.
Proton pump inhibitors are considered the most effective and safest treatment. These medications suppress hydrochloric acid production by inhibiting the pump that produces stomach acid. Epithelial damage is diminished due to less availability of acid. Few studies conducted are over a year in duration. A single study monitored patients over five years. Thjodleifsson and colleagues determined that PPIs were safe. However, Waldenstrum et. al, raise concerns regarding increased acid secretion after discontinuation of PPIs after long-term use.
Prokinetics
As a group, prokinetic agents act on smooth muscle to increase gastric motility, stimulate esophageal peristalsis, lower esophageal sphincter pressure, and increase strength of muscle contractions. Examples of various prokinetic agents include bethanechol, cisapride (removed from the U.S. market) and metoclopramide. Abdominal cramping, blurry vision, drowsiness and hypreprolactinemia are recognized by the Cleveland Clinic Journal of Medicine as common to the prokinetic side effect profile. Only a few small trials exist that significantly characterize these drugs. Many prokinetic agents are not well tolerated at the dosing necessary for GERD management. Therefore, little information is available about their long-term use.
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