Gastroesophageal Reflux Disease (GERD) and Its Most Common Drug List

Gatroesophageal Reflux Disease (GERD) is a digestive disorder, characterized by a chronic persistent back flow of stomach acid in the food pipe (medically known as esophagus). This is different from the occasional reflux of stomach acid, which is known as gastroesophageal reflux (GER). In GERD, this acid reflux happens more than twice a week for few weeks.

Normally, the contents of stomach are limited to the stomach, by a muscular ring present at the lower end of esophagus. This muscular ring is known as lower esophageal sphincter (LES).

LES can be considered as a one-way valve, allowing food to pass from food pipe to stomach, but preventing the stomach contents to flow back into the food pipe. However, in patients of GERD, this LES starts functioning abnormally. It closes improperly or opens more frequently, causing the acidic content of stomach to go back into the food pipe. This acid irritates the lining of esophagus, and causes a burning sensation in the stomach, chest, neck or even throat, commonly referred to as heartburn. The acid may also reflux all the way up to the mouth, producing a sour taste. In some cases, the acid may reflux in parts other than esophagus, like vocal cords or lungs, producing some atypical symptoms.

GERD has a strong association with conditions, like obesity, smoking, alcoholism, aging, pregnancy and some medical conditions, such as hiatal hernia and scleroderma. Certain medications for asthma, hypertension , depression and allergy may also evoke GERD. Unhealthy dietary and lifestyle habits, including large meals, and lying down immediately after meals can also provoke acid reflux.

GERD symptoms can severely affect an individual’s quality of life. However, it can be managed through lifestyle changes, medications and surgery (in few cases).

Symptoms of GERD

The most common symptom of GERD is heartburn. Other symptoms associated with this condition are as follows.

• Chronic dry cough
• Chest pain or discomfort
• Asthma
• Bad breath
• Nausea
• Tooth decay or erosion
• Pain or difficulty while swallowing
• Feeling of a lump in the throat
• Earache
• A sudden increase in salivation

Treatment of GERD

The first and foremost treatment advice for GERD patients is lifestyle modifications. Maintaining a healthy weight, eating smaller meals, keeping a gap of 2 to 3 hours between last meal and bedtime, elevating the head side of the bed and refraining from culprit foods and habits that act as trigger factors of GERD. The trigger factors include foods and beverages, like chocolates, coffee, alcohol, spicy food, peppermint, fatty fried food, citrus fruits and juices, etc. Smoking puts a person at a high risk of developing GERD.

Besides these lifestyle changes, medications are usually included in the treatment of GERD. The treatment through drugs is aimed at relieving the symptoms of GERD and providing ample time for healing of esophageal lesions which can develop due to stomach acids going into food pipe.

These medications are mostly available over-the-counter, and include, antacids, proton pump inhibitors as well as H2 receptor blockers. However, stronger dosage of these medications would require a doctor’s prescription.

Also, some cases may need additional drugs to strengthen the lower esophageal sphincter (LES) and to improve the movement of muscles of stomach and intestine to clear the refluxed acid. These additional drugs include skeletal muscle relaxant and prokinetic drugs.

However, people not responding to lifestyle changes and medications may need surgery to keep the acid reflux in control. These surgeries include, fundoplication (wrapping the upper part of stomach around LES) and LINX device (a ring of magnetic bead at the junction of stomach and esophagus).

The medications used in the treatment of GERD are described below.

1. Drugs that Reduce Gastric Acid Secretion

I. Proton Pump Inhibitors (PPIs)

PPIs are the drugs of choice for even the most severe case of GERD. For esophageal lesions to heal, the pH of stomach should be less than 4, which must be maintained for at least 18 hours in a day. This can be accomplished with the use of PPI only. Hence, PPIs not only relieve the discomfort, but also allow the esophageal lesions to heal.

Proton pumps are crucial to secretion of gastric acid. PPIs bind to the proton pumps and inactivates them, thus blocking the release of gastric acid. The release of acid resumes only when new proton pump is formed, which is usually after 18 hours. This long-lasting effect of PPI gives enough time for healing of esophageal lesions caused by acid reflux.
But, a notable fact is that PPIs become less effective in the presence of food, thus should be taken in an empty stomach only.

Available as: Oral preparations

A. Omeprazole
US-FDA Status: Approved for GERD
Availability: Over-the-counter
Generic name: omeprazole magnesium
Brand name: Prilosec OTC tablet
Side-effects: Stomach, leg or back pain, blisters, bloody or cloudy urine, chills, bleeding crusts on lips, fever, difficulty in urination
Indicated in pregnancy: Only if benefit outweighs fetal risk
Alcohol content: Absent

B. Lansoprazole
US-FDA Status: Approved for GERD
Availability: Over-the-counter
Generic name: lansoprazole
Brand name: Prevacid 24-Hr capsule
Side-effects: Skin rash, diarrhea, nausea, joint pain, vomiting, stomach pain, constipation, anxiety, depression, cough
Indicated in pregnancy: Although no fetal risks have been found, should be used only after medical consultation
Alcohol content: Absent

C. Pantoprazole
US-FDA Status: Approved for GERD
Availability: Prescription
Generic name: pantoprazole sodium
Brand name: Protonix tablet
Side-effects: Dry mouth, abdominal pain, blurred vision, nausea, dry skin, sweating, increased thirst, increased hunger, difficulty in breathing
Indicated in pregnancy: Only if benefits outweigh fetal risks
Alcohol content: Absent

D. Esomeprazole
US-FDA Status: Approved for GERD
Availability: Over-the-counter
Generic name: esomeprazole magnesium
Brand name: Nexium 24-Hr capsule
Side-effects: Chills, peeling of skin, bloating, cough, constipation, dark urine, cough, dizziness, fever
Indicated in pregnancy: Although no fetal risks have been found, should be used only after medical consultation
Alcohol content: Contains traces of alcohol

E. Rabeprazole
US-FDA Status: Approved for GERD
Availability: Prescription
Generic name: rabeprazole sodium
Brand name: Aciphex tablet
Side-effects: Cough or hoarseness, dry mouth, bloating, dark urine, fever, chills, light colored stools, vomiting, nausea
Indicated in pregnancy: Only if benefits outweigh fetal risks
Alcohol content: Absent

II. H2 Blockers

Gastric acid is released by certain cells of the stomach, known as parietal cells. When histamine acts on H2 receptors of these cells, acid is released. H2 blockers block the action of histamine on these receptors, thus reducing the release of stomach acid and relieving the symptoms of GERD.

But, H2 blockers are less effective than PPIs. Also, H2 blockers can maintain the stomach pH more than 4, for only 8 hours in a day. Therefore, healing of esophageal lesions with H2 blockers is seen in few cases only. For these reasons, H2 blockers are mostly indicated in mild cases of GERD.

Available as: Oral preparations

A. Cimetidine
US-FDA Status: Approved for GERD
Availability: Over-the-counter
Generic name: cimetidine
Brand name: Tagamet HB tablet
Side-effects: Dizziness, headache, diarrhea, depression, agitation
Indicated in pregnancy: Although no fetal risks have been found, should be used only after medical consultation
Alcohol content: Absent

B. Ranitidine
US-FDA Status: Approved for GERD
Availability: Over-the-counter
Generic name: ranitidine hydrochloride
Brand name: Zantac tablet
Side-effects: Constipation, headache, vomiting, nausea, dizziness, depression, insomnia
Indicated in pregnancy: Although no fetal risks have been found, should be used only after medical consultation
Alcohol content: Absent

C. Famotidine
US-FDA Status: Approved for GERD
Availability: Over-the-counter
Generic name: famotidine
Brand name: Pepcid AC tablet
Side-effects: Bleeding gums, blood in stools or urine, chest pain, chills, diarrhea, fever, cough or hoarseness
Indicated in pregnancy: Although no fetal risks have been found, should be used only after medical consultation
Alcohol content: Absent

D. Nizatidine
US-FDA Status: Approved for GERD
Availability: Over-the-counter
Generic name: nizatidine
Brand name: Axid AR tablet
Side-effects: Dizziness, headache, rash, swelling, breathing difficulty, abdominal pain, nausea, diarrhea, dry mouth
Indicated in pregnancy: Although no fetal risks have been found, should be used only after medical consultation
Alcohol content: Absent

2. Drugs That Neutralize Gastric Acid

I. Antacids

Unlike PPIs and H2 blockers, antacids do not reduce the gastric acid production. Antacids are basic compounds, which neutralize the acid being released from the stomach.
These act instantly but their effect last for a very short period of time. Hence, these are used occasionally for instant relief of GERD symptoms. Antacids are incapable of healing the esophageal lesions.

Available as: Oral preparations; usually available in combination with other drugs

A. Sodium Bicarbonate with Omeprazole
US-FDA Status: Approved for GERD
Availability: Over-the-counter
Generic name: sodium bicarbonate with omeprazole
Brand name: Zegerid OTC capsule
Side-effects: Bleeding gums, black tarry stools, chest pain, blurred vision, cough, convulsions, blood in urine, dizziness
Indicated in pregnancy: Only if benefits outweigh fetal risk
Alcohol content: Absent

B. Aluminum Hydroxide and Magnesium Trisilicate
US-FDA Status: Approved for GERD
Availability: Over-the-counter
Generic name: aluminum hydroxide and magnesium trisilicate
Brand name: Gaviscon tablet
Side-effects: Rash, itching, hives, chest tightness, trouble breathing, hoarseness, difficulty in swallowing, constipation or diarrhea
Indicated in pregnancy: Only if benefits outweigh fetal risk
Alcohol content: Absent

3. Drugs That Tighten the Lower Esophageal Sphincter

I. Prokinetic Drugs

The motility or movement of the muscles of stomach and intestine is necessary to propel the food, thus preventing its reflux. Prokinetic drugs boost the movement of these muscles, improve the tone of LES, thus facilitate the emptying of stomach. Hence, these drugs prevent the reflux of stomach acid and can be used in mild cases of GERD. However, these are less effective than H2 blockers and PPIs. Also, prokinetic drugs do not permit healing of esophageal lesions.

Available as: Oral preparations

A. Metoclopramide
US-FDA Status: Approved for GERD
Availability: Prescription
Generic name: metoclopramide hydrochloride
Brand name: Reglan tablet
Side-effects: Diarrhea, flatulence, abdominal pain, nausea, dizziness, headache, fatigue, palpitations
Indicated in pregnancy: Only if benefits outweigh fetal risk
Alcohol content: Absent

B. Cisapride
US-FDA Status: Unapproved for GERD
Availability: Discontinued
Generic name: cisapride monohydrate
Brand name: Propulsid tablet
Side-effects: Dark urine, chills, difficulty breathing, fever, dizziness, fast irregular heartbeat, nausea, skin rash, itching, cardiac complications
Indicated in pregnancy: Usually not indicated, but can be given if benefits outweigh fetal risk
Alcohol content: Absent

II. Baclofen

This drug belongs to a drug class, known as GABA-mimetic skeletal muscle relaxant. It is usually not indicated in GERD, but its role in GERD has been a matter of active research lately. Baclofen acts in the spinal cord, where it activates receptors of a particular brain chemical, known as gamma- Aminobutyric Acid (GABA). By doing so, it reduces spasticity of muscles. In GERD, baclofen works by reducing the frequency of relaxation or opening of lower esophageal sphincter (LES), thus preventing acid reflux and relieving symptoms of GERD.

Available as: Oral preparations

US-FDA Status: Approved for GERD
Availability: Prescription
Generic name: baclofen
Brand name: Baclofen tablet
Side-effects: Chest pain, bloody or dark urine, hallucinations, skin rash, mental depression, blurred vision
Indicated in pregnancy: Only if benefits outweigh fetal risk
Alcohol content: Absent

OTC Avaialable for GERD

Various over-the-counter medications available for GERD, in different countries are described in the table below.

Although there are several over-the-counter medications available for GERD, you must seek medical help prior to consuming these medications. Self-medication is not recommended.