Chronic Reflux

    Chronic reflux

    Success stories of Gaviscon treatment

    The patient

    Fifty-two-year-old John has been treated with proton pump inhibitors (PPIs) for the last 2 months to treat his gastro-oesophageal reflux disease (GORD). In the last 2 weeks he has started to experience regurgitation and heartburn again. His symptoms occur after eating dinner 3–4 times a week and are especially problematic on weekends. He is also struggling with heartburn at night, which is making it difficult for him to sleep.

     

    Understanding the underlying cause(s)

    GORD patients are often treated with PPIs to manage their symptoms.(1) PPIs offer relief to these patients by reducing gastric acid secretion in the stomach, causing the acid pocket to decrease in size and acidity.(2) However, some patients may experience breakthrough symptoms, including regurgitation and heartburn.(3) Results show that 45% of patients with GORD experience such symptoms whilst on PPI therapy.(4)

    There are several reasons for why these breakthrough symptoms may arise during PPI treatment. Firstly, PPIs only alter the nature of the reflux but do not control the frequency of reflux events.(2) Reduced amounts of weakly acidic refluxate are still able to pass into the oesophagus at the same rate. Additionally, PPIs only target the acid in the refluxate and do not alter other aggressors like bile and pepsin, which can also contribute to reflux symptoms.(3,5,6)

     

    Consultation advice

    Firstly, you should reassure John that his symptoms are not uncommon for individuals using PPIs.(4) A thorough medical history of John’s symptoms should be carried out.(7) This should cover what his symptoms are, when they occur and how severe were the symptoms before and after PPI treatment.

    In addition, you should also consider the following:

    1. Lifestyle modifications

      John’s symptoms appear to be post-prandial, more specifically after consuming dinner in the evenings. If he is eating large meals, particularly before going to bed, advise him to reduce the size of his meals and to avoid eating late at night. You should also advise him to avoid any reflux triggering foods that could be contributing to his symptoms.(7,8)

    2. Evaluate the prescribed PPI therapy

      Check that John is taking his PPI medication correctly before increasing his dose or changing his medication. For example, is he taking his PPIs before meals, particularly before breakfast?(7)

      If he is taking his PPI treatment as prescribed, consider switching to another PPI or increasing the dose. Take into consideration John’s preferences and clinical circumstances and/or seek specialist advice.(7,8)

    3. Co-therapy with alginates

      Consider an alginate therapy to treat John’s breakthrough symptoms in addition to his PPIs.(7,8) Alginates have a different mode of action to PPIs and can address symptoms that are not maintained with PPIs. For example, they form a reflux-suppressing barrier, which makes it more difficult for stomach contents, including bile, pepsin and acid, to pass into the oesophagus.(5) Additionally, alginates have been shown to adhere to the oesophageal mucosa, potentially protecting it against acid/bile acid-induced damage.(9) Studies have shown that alginate-PPI co-therapy can reduce breakthrough symptoms in patients with GORD(10-12) and improve patient treatment satisfaction.(13)

    4. H2RAs

      If John continues to have an inadequate response with PPI therapy, consider offering him histamine 2 receptor antagonist (H2RA) therapy.(14)

    5. Referral

      Refer John to a specialist if he displays symptoms with significant acute gastrointestinal bleeding (immediately) or if his symptoms persist.(15) He may require an endoscopy or a surgical intervention.(15)

    References

    1. Sigterman KE, van Pinxteren B, Bonis PA, et al. Short-term treatment with proton pump inhibitors, H2-receptor antagonists and prokin6etics for gastro-oesophageal reflux disease-like symptoms and endoscopy negative reflux disease. Cochrane Database Syst Rev 2013;2013(5):CD002095
    2. Roholf WO, Bennink RJ, Boeckxstaens GE. Proton pump inhibitors reduce the size and acidity of the acid pocket in the stomach. Clin Gastroenterol Hepatol 2014;12(7):1101–7
    3. Kahrilas PJ, Jonsson A, Denison H, et al. Regurgitation is less responsive to acid suppression than heartburn in patients with gastroesophageal reflux disease. Clin Gastroenterol Hepatol 2012;10(6):612–19
    4. El-Serag H, Becher A, Jones R. Systematic review: persistent reflux symptoms on proton pumpinhibitor therapy in primary care and community studies. Aliment Pharmacol Ther 2010;32(6):720–37
    5. Strugala V, Avis J, Jolliffe IG, et al. The role of an alginate suspension on pepsin and bile acids - key aggressors in the gastric refluxate. Does this have implications for the treatment of gastro-oesophageal reflux disease? J Pharm Pharmacol 2009;61(8):1021–28
    6. Farre R, Fornari F, Blondeau K, et al. Acid and weakly acidic solutions impair mucosal integrity of distal exposed and proximal non-exposed human oesophagus. Gut 2010;59(2):164–69
    7. Kahrilas PJ, Boeckxstaens G, Smout AJ. Management of the Patient with Incomplete Response to PPI Therapy. Best Pract Res Clin Gastroenterol 2013;27(3):401–14
    8. De Argila CM, Belinchon MR, Martinez AA. Primary Care Practitioners’ Views on the Use of Proton Pump Inhibitors associated with Alginate-Antacids for better gastroesophageal reflux disease symptom control: results of a national survey in Spain. Open Journal of Gastroenterology 2014;4:335–45
    9. Woodland P, Batista-Lima F, Lee C, et al. Topical protection of human esophageal mucosal integrity. Am J Physiol Gastrointest Liver Physiol 2015;308(12):G975–80
    10. Reimer C, Lødrup AB, Smith G, et al. Randomised clinical trial: alginate (Gaviscon Advance) vs. placebo as add-on therapy in reflux patients with inadequate response to a once daily proton pump inhibitor. Aliment Pharmacol Ther 2016;43:899–909
    11. Coyle C, Crawford G, Wilkinson J, et al. Randomised Clinical Trial: Addition of alginate-antacid (Gaviscon Double Action) to proton pump inhibitor therapy in patients with breakthrough symptoms. Aliment Pharmacol Ther 2017;45(12):1524–33
    12. Bytzer P, Coyle C, Pavion T, et al. Add-on alginate to proton pump inhibitor therapy in patients with breakthrough symptoms: a post-hoc analysis using a clinically relevant responder rate. Presented at Gastro Update Europe 2017
    13. Mueller M, Labenz G, Borkenstein M, et al. Alginate as add-on therapy for GORD with insufficient PPI effect: The LOPA III trial. Presented at UEGW 2018 (Poster 1783)
    14. NICE. Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management. 2014. Available: https://www.nice.org.uk/guidance/cg184 [accessed August 2019]
    15. NICE. NICE Pathways: Managing gastro-oesophageal reflux disease in adults. 2019. Available: https://pathways.nice.org.uk/pathways/dyspepsia-and-gastro-oesophageal-reflux-disease/managing-gastro-oesophageal-reflux-disease-in-adults [accessed August 2019]

     

    RB-M-02499
    Date of preparation: June 2020

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