Gastroesophageal

Reflux
Disease (GERD)

Bassem Almalki B.Sc.Pharm, PharmD, BCPS

Assistant Professor & Solid Organ Transplant Clinical
Pharmacist
Learning outcomes
• Recognize the clinical presentation of GERD
• Develop a therapeutic plan for the management of GERD
• Construct a safety and efficacy monitoring plan for patients
with GERD
Background
• Defined as "symptoms or
complications resulting from refluxed
stomach contents into the esophagus
or beyond, into the oral cavity
(including the larynx) or lung"
• GERD prevalence in adults in
the United States is approximately
20% and is commonly seen in those
older than 50 years
• Symptoms occurring twice weekly or
more and adversely affect the well-
being of patients

https://www.healthlinkbc.ca/health-topics/gastroesophageal-reflux-
disease-gerd
Digestive System

https://nurseslabs.com/digestive-system/
 Parietal cells are epithelial cells
in the stomach that secrete
hydrochloric acid (HCl), which
contain receptors for histamine,
gastrin, and acetylcholine

Stomach Chief cells in the stomach,

secret pepsinogen -> pepsin
Pathophysiology
Composition of Refluxate

PH Volume
• If the pH of the refluxate is less than 2, • An increase in gastric volume may increase
esophagitis may develop secondary to both the frequency of reflux and the
protein denaturation amount of gastric fluid available
• Pepsinogen is activated to pepsin at this pH
• Alkaline esophagitis (duodenogastric
reflux)can also happn (combination of acid,
pepsin, and/or bile)
 Obesity

Tobacco smoking
Risk
factors Alcohol consumption

Genetic predisposition
Lower Esophageal
Sphincter (LES)
Pressure

• Reflux may occur following

spontaneous transient LES
relaxations (e.g., belching)
• Increase in intra-abdominal
pressure (stress reflux, e.g.,
coughing)
• LES can be atonic (scleroderma)

https://gastrohealth.com/news/patient-care/gastroesophageal-reflux-disease-a-
clinical-discussion
Anatomic
Factors
• Patients with
hypotensive LES
pressures and large
hiatal hernias are
more likely to
experience
gastroesophageal
reflux

https://www.google.com/search?q=hiatal+hernia&sxsrf=AJOqlzV2WG522y16w4ft
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Esophageal Clearance
• Acid spends too much time in contact with
the esophageal mucosa (acid production maybe normal)
• Swallowing contributes to esophageal clearance by increasing
salivary flow
• Saliva contains bicarbonate that buffers the residual gastric
material on the surface of the esophagus (decreases with age)
• Swallowing is decreased during sleep leading to nocturnal GERD
Mucosal Resistance
• Within the esophageal mucosa and submucosa,
there are mucus-secreting glands
• Esophageal mucosa is damaged, via hydrogen
ions diffusing into the mucosa, with repeated
exposure to the refluxate
Gastric Emptying/Increased Intra-
abdominal Pressure
• Fatty foods may increase postprandial
gastroesophageal reflux by increasing gastric
volume, delaying the gastric emptying rate, and
decreasing the LES pressure
• Obesity is considered an independent risk factor
for GERD due to increased intra-abdominal
pressure and reduced LES pressure
Helicobacter pylori
• Routine screening for H. pylori is not
recommended as part of the diagnosis and
management of GERD
Complications
• Esophagitis Nonerosive reflux
• repeatedly exposed to refluxed gastric content disease
• Esophageal strictures
• Extraesophageal reflux syndromes
• chest pain, chronic cough, or asthma
• Barrett’s esophagus
• Esophageal adenocarcinoma
Clinical Presentation
 Esophageal
symptoms
Clinical
Presentation
Esophageal
tissue injury
Clinical Presentation

Signs and Symptoms

• Heartburn
• Regurgitation Mild
• Chest pain
• Bleeding
• Dysphagia (in severe cases such as Barrett's esophagus) Sever

Tests
• Upper endoscopy
• In patients who fails initial empiric trial of acid suppression therapy or sever S&S
• Biopsies are needed to identify Barrett’s esophagus and adenocarcinoma
• Ambulatory reflux (pH) monitoring
Clinical
Presentation

• Proven GERD should be established

before long-term acid suppression
therapy is considered
• In the case of functional heartburn,
eosinophilic esophagitis, reflux
hypersensitivity, or other nonreflux
GI disorders, acid suppression
therapy may not be the most
appropriate choice for treatment

https://www.google.com/search?q=endoscopy&sxsrf=AJOqlzVbyhF9thMj2MEpxA
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Treatment
Goal
Alleviate or eliminate Decrease the frequency
patient’s symptoms or recurrence
and improve health- and duration of
related quality of life gastroesophageal reflux

Promote healing of the

Prevent complications
injured mucosa
Treatment

Nonpharmacologic Interventional

Pharmacologic
Nonpharmacologic
• Elevate the head end of the bed (increases esophageal
clearance)
• Weight reduction in obese patients
• Avoid foods that have a direct irritant effect on the
esophageal mucosa
• Behaviors that may reduce esophageal acid exposure
• Eat small meals and avoid sleeping immediately after
meals (sleep after 3 hours if possible; decreases gastric
volume)
Nonpharmacologic
• Stop smoking
• Always take drugs in the sitting upright or standing position
and with plenty of liquid, especially for those that have a
direct irritant effect on the esophageal mucosa (e.g.,
bisphosphonates, tetracyclines, quinidine, potassium
chloride, iron salts, aspirin, nonsteroidal anti-inflammatory
drugs)
Pharmacologic
Typical GERD symptoms/mild heartburn

• Individualized lifestyle modifications

• Patient-directed therapy with antacids and/or nonprescription
H2RAs or nonprescription PPIs) only as needed
• If symptoms are unrelieved with lifestyle modifications and nonprescription
medications after 2 weeks, patient should seek medical attention

Symptomatic relief of GERD

• Individualized lifestyle modifications

• Prescription-strength H2RAs or prescription-strength PPIs scheduled
• If symptoms recur, consider maintenance therapy

Moderate-to-severe symptoms/ Erosive esophagitis

• PPIs (up to twice daily for up to 8 weeks) and maintenance therapy therafter
 • Used only in mild cases
Antiacids • MOA: neutralizing hydrochloric acid in gastric
secretions
• Onset of action: 30-60 minutes
• DDIs: fluoroquinolones, doxycycline,
levothyroxine
Adverse Drug Reactions
• Stomach upset and diarrhea may occur
• Magnesium toxicity in CKD
Histamine
H2 • Used in mild and moderate - severe cases
(second line)

receptor • MOA: H2 receptor antagonist prevents the

release of stomach acid from the parietal cells
antagonists • Onset of action: within 1 hour

(H2RAs) • DDIs: cimetidine strong CYP450 inhibitor

• Monitor for kidney function
Adverse Drug Reactions
• Confusion, hallucinations, lack of energy, seizure
 • Used in mild and moderate - severe cases (first line)
Proton Pump • MOA: irreversibly binding to and inhibiting the hydrogen-
potassium ATPase pump that resides on the luminal surface
Inhibitors of the parietal cell membrane
• Onset of action: 2-3 days
(PPIs) • DDIs: CYP2C19 inhibitors omeprazole and esomeprazole may
interact with clopidogrel
• Administration: 30-60 minutes before meals
• Further evaluation is recommended for nonresponders to PPI
therapy
• The efficacy in treating GERD is similar among all of the PPIs
• Dexlansoprazole is unique in that the capsule is a dual
delayed-release formulation (useful in nocturnal symptoms)
Adverse Drug Reactions
• Osteoporosis and hip fracture, hypomagnesaemia,
vit B12 deficiency, clostridium difficile, community-
acquired pneumonia, AKI
Nonacid Suppression Therapies;
Sucralfate
• Sucralfate 1 g three times daily
• Recommended in pregnant GERD patients
• MOA: forms a complex by binding with positively
charged proteins in exudates, forming a viscous
paste-like, adhesive substance
• Onset of action: 1-2 hours
• Caution in patients with DM and CKD
• ARs: GI adverse reactions
Combination Therapy
• Data to support combination therapy are limited
• H2RA at bedtime can be added to PPI therapy for
nocturnal symptoms
Interventional

Antireflux surgery Bariatric surgery

Endoscopic
therapies
Follow-up
• 8 to 16 weeks to assess effectiveness of acid-
suppression therapy
• Recommend alternative therapy when necessary;
attempt to deprescribe PPIs if possible
• Rebound acid hypersecretion may occur when PPIs are
withdrawn making deprescribing of PPIs difficult
• A small subset of patients may continue to fail
treatment despite therapy with high doses of H2RAs or
a PPI
• Antireflux surgery, magnetic sphincter augmentation,
and endoscopic therapies may have a role in refractory
GERD
Self-assessment
Patient Case
• A 52-year-old male patient presents to his primary care
physician and reports bothersome heartburn symptoms for
the last 4 months with occasional regurgitation. The patient
reports that the heartburn symptoms are occurring most
days of the week. The patient also reports that he has
developed painful, difficult swallowing over the last several
months. What is the most appropriate recommendation for
management of the patient’s heartburn symptoms?
1. Start omeprazole 20 mg daily and recommend antireflux surgery.
2. Start omeprazole 20 mg daily and recommend endoscopy.
3. Encourage lifestyle modifications and recommend ambulatory
reflux monitoring.
4. Start omeprazole 20 mg twice daily and recommend manometry.
Thank you !