Management of gastroesophageal reflux disease in adults: a pharmacist's perspective

Functional Food in Relation to Gastroesophageal Reflux Disease (GERD)

Gastroesophageal reflux disease (GERD) is a common esophageal disorder characterized by troublesome symptoms associated with increased esophageal acid exposure. The cornerstones of therapy in this regard include treatment with acid-suppressive agents, lifestyle modifications, and dietary therapy, although the latter has not been well defined. As concerns regarding long-term proton pump inhibitor (PPI) use continue to be explored, patients and healthcare providers are becoming increasingly interested in the role of diet in disease management. However, dietary interventions lack evidence of the synthesis effect of functional foods. The following is a review of dietary therapy for GERD, emphasizing food components' impact on GERD pathophysiology and management. Although the sequential dietary elimination of food groups is a common practice, the literature supports broader intervention, including reduced overall sugar intake, increased dietary fiber, and changes in overall eating practices. While the primary concern of food companies is to provide safe products, the caloric, nutritional, and functional composition of foods is also generating interest in the food industry due to consumers' concerns.

Indirect Effects of Racial Discrimination on Health Outcomes Through Prefrontal Cortical White Matter Integrity

BACKGROUND

Racial discrimination is consistently associated with adverse health outcomes and has been linked to structural decrements in brain white matter. However, it is unclear whether discrimination-related neuroplastic changes could indirectly affect health outcomes. Our goal was to evaluate indirect associations of racial discrimination on health outcomes through white matter microstructure in a sample of trauma-exposed Black women.

METHODS

A trauma study in an urban hospital setting recruited 79 Black women who received a history and physical examination to assess medical disorders (compiled into a summed total of disorder types). Participants reported on experiences of racial discrimination and underwent diffusion tensor imaging; fractional anisotropy values were extracted from white matter pathways previously linked to racial discrimination (corpus callosum, including the body and genu; anterior cingulum bundle; and superior longitudinal fasciculus) and entered into mediational models.

RESULTS

Indirect effects of racial discrimination on medical disorders through left anterior cingulum bundle fractional anisotropy were significant (β = 0.07, SE = 0.04, 95% CI [0.003, 0.14]) after accounting for trauma and economic disadvantage. Indirect effects of racial discrimination on medical disorders through corpus callosum genu fractional anisotropy were also significant (β = 0.08, SE = 0.04, 95% CI [0.01, 0.16]).

CONCLUSIONS

Racial discrimination may increase risk for medical disorders via neuroplastic effects on microstructural integrity of stress-sensitive prefrontal white matter tracts. Racial discrimination-related changes in these tracts may affect health behaviors, which, in turn, influence vulnerability for medical disorders. These data highlight the connections between racial discrimination, prefrontal white matter connections, and incidence of medical disorders in Black Americans.

Intrauterine exposure to omeprazole increases the risk of teeth morphological anomalies in the offspring of a murine model

Conditions experienced in early life have long-lasting effects on offspring health. Despite this, little is known about how maternal exposure to drugs during pregnancy affects offspring teeth morphogenesis. In humans, omeprazole is a common drug used to mitigate Gastroesophageal Reflux Disease. Importantly, omeprazole is a non-specific proton-pump inhibitor, which may inhibit the proton pumps expressed in the developing tooth germ. To date, however, the effects of intrauterine life exposure to omeprazole on offspring tooth development remain unknown. In this study, we addressed this gap in a murine model. Pregnant female Swiss mice were exposed to daily doses of 40 mg/kg of omeprazole from the 5^th to the 17^th day of pregnancy and the effects of such exposure on offspring odontogenesis parameters such as morphological abnormalities, disruptions in the ameloblast and odontoblast layers and the presence of dentin matrix were measured. Omeprazole exposure significantly increased the prevalence (control: 21.6%; treatment: 60%; p = 0.001) and the risk (posterior mean and 95% credible interval; control: 0.230 [0.129; 0.347]; treatment: 0.593 [0.449; 0.730]) of offspring teeth morphological abnormalities, although there were no statistically significant effects of omeprazole exposure on other parameters of tooth development. These findings suggest that there are potential side-effects to offspring oral health of omeprazole use during pregnancy.

Potential effects of carbon monoxide donor and its nanoparticles on experimentally induced gastric ulcer in rats

The prevalence of gastric ulcers is increasing worldwide, especially those brought on by non-steroidal anti-inflammatory drugs (NSAIDS), so prevention is extremely crucial. The protective potential of carbon monoxide (CO) in several inflammatory disorders has been clarified. The goal of the current study was to investigate the gastroprotective effect of CO produced by its pharmacological donor (CORM2) and its nanoparticles (NPs) against indomethacin (INDO)-induced ulcers. Investigations on CORM2's dose-dependent effects were also conducted. For induction of gastric ulcer, 100 mg kg^-1 of INDO was given orally. Before ulcer induction, CORM2 (5, 10, and 15 mg kg^-1), CORM2 nanoparticles (5 mg kg^-1), or ranitidine (30 mg kg^-1) were given intraperitoneally for 7 days. Ulcer score, gastric acidity, gastric contents of malondialdehyde (MDA), nitric oxide (NO), heme oxygenase-1 (HO-1), and carboxyhemoglobin (COHb) blood content were estimated. Additionally, gene expression of nuclear factor erythroid 2-related factor 2 (NRF2) and immunohistochemical staining of cyclooxygenase-1 (COX-1) as well as cyclooxygenase-2 (COX-2) were analyzed. Results demonstrated a substantial dose-dependent decrease in ulcer score, pro-inflammatory indicators, and oxidative stress markers with CORM2 and its NPs. Furthermore, CORM2 and its NPs markedly increased NRF2, COX-1, and HO-1, but CORM2 NPs outperformed CORM2 in this regard. In conclusion, the CO released by CORM2 can protect against INDO-induced gastric ulcers dose dependently, and the highest used dose had no effect on COHb concentration.

Protocol of a randomized, double-blind, placebo-controlled study of the effect of probiotics on the gut microbiome of patients with gastro-oesophageal reflux disease treated with rabeprazole

Background

For patients with gastro-oesophageal reflux symptoms, the preferred treatment is proton pump inhibitor (PPI) administration for approximately 8 weeks. However, long-term use of PPIs can cause gut microbiome (GM) disturbances. This study is designed to evaluate the effect of probiotics combined with a PPI on the GM and gastrointestinal symptoms of patients with gastro-oesophageal reflux disease (GERD).

Method

This is a randomized, double-blind, placebo-controlled trial. A total of 120 eligible patients with GERD will be randomized into the experimental group or the control group. The treatment includes two phases: the initial treatment period lasts 8 weeks (weeks 1–8), and the maintenance treatment period lasts 4 weeks (weeks 9–12). During the initial treatment period, the experimental group will take rabeprazole and LiHuo probiotics, and the control group will take rabeprazole and a probiotic placebo; during the maintenance treatment period, the experimental group will take LiHuo probiotics, and the control group will take a probiotic placebo. The primary measure is the change in the GM. The secondary measures are the Reflux Disease Questionnaire (RDQ) score, Gastrointestinal Symptom Rating Scale (GSRS) score, faecal metabolome (FM), body mass index, Los Angeles grade of oesophagitis, adverse event (AE) rate and treatment compliance. Each outcome indicator will be assessed at day 0 (before administration), day 28 and/or 56 (during administration), and day 84 (end of administration) to reveal intragroup differences. AEs will be monitored to assess the safety of LiHuo probiotics.

Discussion

This will be the first trial to use the intestinal flora metagene method to analyse the effects of probiotics on patients with GERD receiving long-term PPI treatment. The goal is to provide evidence for the use of probiotics to reduce intestinal flora disorders and other symptoms of gastrointestinal discomfort in patients with GERD who have used PPIs for a long period.

Trial registration

Chinese Clinical Trial Registry (ChiCTR) (NO. ChiCTR2000038409). Registered on November 22, 2020, http://www.chictr.org.cn/showproj.aspx?proj=56358.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-022-02320-y.

Review of recent evidence on the management of heartburn in pregnant and breastfeeding women

Gastroesophageal reflux disease (GERD) is one the most common medical complaints in pregnant women. Some women continue to experience GERD symptoms after delivery. Effective management of GERD symptoms is important to improve productivity and quality of life. Management of heartburn in pregnant and breastfeeding women involves lifestyle modifications, dietary modifications, non-pharmaceutical remedies and pharmaceutical drugs. For most patients, lifestyle/dietary modifications are helpful in reducing GERD symptoms. For patients who require a more intense intervention, various types of pharmaceutical drugs are available. However, the suitability of each treatment for use during pregnancy and lactation must be taken into consideration. This article explores the reported efficacy and safety of these treatment options in pregnant and breastfeeding women. Recommended treatment algorithm in pregnant and breastfeeding women have been developed.

The views of African and Middle Eastern Gastroenterologists on the management of mild-to-moderate, non-erosive gastro-esophageal reflux disease (GERD)

INTRODUCTION

Gastro-esophageal reflux disease (GERD) is a common gastrointestinal disorder that occurs when backflow of the gastric contents into the esophagus results in troublesome symptoms. Though GERD has been extensively studied in Western populations, literature on the management of GERD in patients in Africa and Middle East (AME) is scarce.

AREAS COVERED

In this review, we provide an overview of the management of mild-to-moderate GERD in AME. Here we focus on the efficacy and safety of currently available treatments for GERD to help physicians and community pharmacists appropriately manage patients with mild-to-moderate GERD in the primary healthcare setting, detailing specific situations and patient scenarios that are relevant to the region, including management of GERD during Ramadan and post-bariatric surgery.

EXPERT OPINION

Under-appreciation of the burden of GERD in the region has resulted in a lack of consensus on management. Barriers that currently prevent the adoption of treatment guidelines in the primary healthcare setting may include lack of availability of local guidelines and referral systems, a paucity of region-specific research, and dogmatic adherence to traditional practice. By increasing awareness, strengthening knowledge, and by more effective utilization of resources, physicians and pharmacists could optimize GERD management strategies to better support patients.

Understanding the Patient PPI Journey: Results of a Survey on PPI Treatment Initiation and Patient Experience

INTRODUCTION

Proton pump inhibitors (PPIs) used in the management of gastro-esophageal reflux disease (GORD) are among the most frequently prescribed classes of drug worldwide. Currently, however, physicians are prescribing PPIs for extended periods, often without an indication, which is not in line with current guidance and therefore preventing appropriate reflux management. Inappropriate or excessive PPI prescribing is becoming increasingly visible, yet there is currently little research available on the impact such current practice has on the patient experience. This study aims to understand patient attitudes toward their PPI treatment and the impact current PPI prescribing patterns have on the patient experience.

METHODS

An online survey of current and previous users of PPI for GORD was conducted in the UK and Germany. Topics covered included prior steps taken before first consultation with a physician, initial recommendations, PPI treatment initiation and duration, use of PPI, management of reflux whilst taking a PPI, stopping PPI treatment, and patient attitudes.

RESULTS

Among 566 patient participants (UK, n = 372; Germany, n = 194) 69% to 79% reported being prescribed medication at their first visit to a physician, of which 61% to 68% were prescribed a PPI either alone or combined with another treatment. 41% to 48% of patients answered "don't know" when asked how long they expected to continue taking their PPI. 49% to 50% of patients currently on PPIs also reported having concerns with regards to long-term treatment. 70% of patients recalled being well informed on dosage and treatment regimens. However, other safety and usage information was reported as being less frequently discussed.

CONCLUSIONS

Although patients reported concerns regarding ongoing long-term PPI treatment, this was not reflected in the prescribing pattern from physicians. More can be done to ensure patients are fully informed about their PPI treatment at consultation. Findings also suggest a disconnect exists between standard treatment guidelines and prescribing patterns, as experienced by patients.

The Relationship between Serum Total Oxidant Status, Total Antioxidant Status, and Oxidative Stress Index with Severity Levels of Gastroesophageal Reflux Disease: A Literature Review

Gastroesophageal reflux disease (GERD) is a global health problem in which the prevalence is increasing over periods. This disease is a significant cause of disorders in the upper gastrointestinal tract with very complex pathogenesis. Oxidative stress (OS) due to gastric acid reflux plays a role in the inflammatory response of the esophageal epithelium. Several OS markers have been widely studied and are thought to affect the severity degree of the esophageal mucosa. However, there has been no research on total oxidant status (TOS), total antioxidant status (TAS), and OS index (OSI) in the adult with GERD; hence the aim of this review was to determine the association between TOS, serum TAS, and OSI with the GERD degree. A literature review was conducted by searching articles related to the TOS, TAS, OSI, and its correlation with GERD degree on an online database, particularly Pubmed and Google scholar. We conclude that TAS and OSI might influence the severity of GERD; however, further clinical study is needed to prove this theory.

Different Effects of Aerobic Exercise and Diaphragmatic Breathing on Lower Esophageal Sphincter Pressure and Quality of Life in Patients with Reflux: A Comparative Study

BACKGROUND Gastroesophageal reflux disease (GERD) is a worldwide disorder with an increasing prevalence. The quality of life (QOL) of the patients may be influenced by reflux disease. Diaphragmatic breathing (DB), as well as aerobic exercise (AE), may improve the symptoms of reflux disease, although it remains a controversial issue. The aim of this study was to compare the effects of AE and DB on QOL and lower esophageal sphincter (LES) pressure of patients with moderate to severe reflux. METHODS This was a case-control study that was conducted for 8 weeks among patients with moderate to severe GERD. The block randomization method was designed to randomize patients into three groups (AE, DB, and control) to achieve equal sample sizes. The control group received omeprazole 20 mg once daily. The other groups, in addition to omeprazole, received AE and DB. QOL and LES pressure were measured before and after the study by Questionary and Manometry method, respectively. RESULTS 75 patients were enrolled in this study. Positive effects of DB on LES pressure was approved (p = 0.001). DB had significantly more effects on QOL than aerobic exercise (p = 0.003). AE can significantly improve QOL in patients (p = 0.02) but no significant change in LES pressure (p = 0.38). There was no change in the control group for both variables. CONCLUSION AE had no effects on LES pressure but can improve QOL of the patients. DB had more effects on QOL than AE, so injured or disable patients with reflux who cannot do AE, can benefit from DB to improve their reflux symptoms.

Impact of chronic medications in the perioperative period: mechanisms of action and adverse drug effects (Part I)

Background: This review article discusses the pharmacology of the most commonly used chronic medications in patients undergoing elective surgical procedures. The mechanism of action and adverse side effects of cardiovascular medications (e.g., beta blockers, alpha-2 agonist, calcium channel blockers, ACE inhibitors, diuretics), lipid-lowering drugs, gastrointestinal medications (H2-blockers, proton pump inhibitors), pulmonary medications (inhaled β-agonists, anticholinergics,), antibiotics (tetracyclines, clindamycin and macrolide, linezolid), opioids and non-opioids analgesics (NSAIDs, COX-2 inhibitors, acetaminophen), gabapentanoids, erectile dysfunction (ED) drugs, and psychotropic drugs (tricyclic antidepressants [TCAs], monoamine oxidase inhibitors [MAOI], selective serotonin reuptake inhibitors [SSRIs], serotonin norepinephrine reuptake inhibitors [SNRIs], and cannabinol-containing drugs) will be reviewed.Materials and Methods: An online search was conducted from January 2000 through February 2021 with the Medline database through PubMed and Google Scholar using the following search terms/keywords: "chronic medications in the perioperative period", and "chronic medications and anesthetic implications." In addition, we searched for anesthetic side effects associated with the major drug groups.Results and Conclusions: An understanding of the pharmacology and pharmacokinetics of most used chronic medications is important to avoid untoward outcomes in the perioperative period. These drug interactions may result in altered efficacy and toxicity of the anesthetic medications administered during surgery. These drug-drug interactions can also effect the morbidity, mortality, and recovery time of surgical patients. Part I of this two-part review article focuses on the mechanisms of action and adverse side effects of the chronic medications most commonly taken by surgical patients in the preoperative period.

Barrett's Esophagus and Intestinal Metaplasia

Intestinal metaplasia refers to the replacement of the differentiated and mature normal mucosal epithelium outside the intestinal tract by the intestinal epithelium. This paper briefly describes the etiology and clinical significance of intestinal metaplasia in Barrett’s esophagus. This article summarizes the impact of intestinal metaplasia on the diagnosis, monitoring, and treatment of Barrett’s esophagus according to different guidelines. We also briefly explore the basis for the endoscopic diagnosis of intestinal metaplasia in Barrett’s esophagus. The identification techniques of goblet cells in Barrett’s esophagus are also elucidated by some scholars. Additionally, we further elaborate on the current treatment methods related to Barrett’s esophagus.

Survey-Based Analysis of Current Trends for Prescribing Gastrointestinal Protectants among Small-Animal General Practitioners in Portugal

In both human and veterinary healthcare, gastrointestinal protectants (GIPs) are considered a staple of clinical practice in that they are prescribed by general practitioners (GPs) and specialists alike. Concerning GIP use, overprescription of proton pump inhibitors (PPIs) has become a growing concern among human healthcare providers. This trend has also been documented within veterinary practice, prompting the American College of Veterinary Internal Medicine (ACVIM) to publish a consensus statement in 2018 concerning evidence-based indications for GIP use. This observational cross-sectional study evaluated self-reported prescribing protocols among Portuguese GPs to determine whether there is adherence to the consensus guidelines. Respondents were Portuguese GPs recruited by social media posts in veterinarian online forums. Data were collected from 124 respondents concerning their GIPs of choice and their rationales for prescribing them. Data were mined for prescription patterns and protocols. Among GIPs, PPIs were prescribed more often. Rationales for use included gastrointestinal ulceration and erosion (GUE), prophylactic management of nonerosive gastritis, pancreatitis, reflux esophagitis, and steroid-induced ulceration. Once-daily administration of PPIs was the most frequent dosing regime among respondents. Ninety-six percent of PPI prescribers advocated that the drug be administered either shortly before or at mealtime. Forty-nine percent of respondents supported long-term use of PPIs. Fifty-nine percent of respondents acknowledged discontinuing PPIs abruptly. This study supports that Portuguese GPs commonly prescribe GIPs in accordance with ACVIM recommendations to medically manage GUE. However, misuse of GIPs does occur, and they have been prescribed where their therapeutic value is debatable. Educational strategies should target GPs in an effort to reduce GIP misuse.

A retrospective study on the evaluation of the symptoms, medications and improvement of the quality of life of patients undergoing robotic surgery for gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is a common gastrointestinal disorder requiring lifestyle adaptations and administration of medications. Another approach is the surgical treatment of GERD through laparoscopic or robotic operations. The aim of the present study was to investigate the improvement of symptoms and quality of life of patients with GERD, before and after robotic surgical restoration using the Nissen robotic fundoplication technique. The potential effects of body weight, age and sex, as well as the response to medications and progress over time, were also assessed. A retrospective study was conducted in a tertiary hospital between October 2019 and March 2020. Data were collected and recorded from 144 patients who underwent robotic surgery, using the Nissen fundoplication technique, during the period 2009-2019. All patients involved in this analysis pre-operatively exhibited severe symptoms of heartburn and reflux, as well as poor quality of life. All of these symptoms were re-examined after surgery, and a marked decrease was observed with respect to their frequency and intensity. Improvement was not affected by body mass index, whereas older patients exhibited greater improvement. Women initially experienced more severe symptoms before the surgery, but they appeared to respond as well as the male patients. The long-term beneficial effects of surgery for up to the 10-year period studied were validated. After the robotic surgical rehabilitation, the vast majority of patients overcame the unpleasant symptoms of GERD and stayed off their medications. More than 4/5 of the patients were satisfied after surgery. In conclusion, restoration of GERD, using Nissen robotic fundoplication, led to the minimization of symptoms and to a marked improvement in the quality of life of patients.

Effectiveness of a Patient-Centered Weight Management Model in a Community Pharmacy: An Interventional Study

PURPOSE

The aim of this study was to evaluate the provision of a professional pharmaceutical patient-centered model in a weight management program and optimization of the medication in a Spanish community pharmacy.

PATIENTS AND METHODS

This was a single-group intervention study with a mean follow-up period of 8.2 months (sd 2.3). Patients ≥18 years old seeking to lose weight or improve eating habits were recruited. On the first visit, the pharmacist collected patients' sociodemographic and anthropometric variables, dietary history and lifestyle habits, biochemical measurements and other clinical and therapeutic data. The intervention was based on the Spanish Society of Community Pharmacy recommendations for diet and exercise and for pharmacotherapy management. The follow-up included a two-month visit and a final visit.

RESULTS

A total of 330 patients were included (80% women; mean age 51.3 years old (sd 15.3)). A statistically significant reduction in anthropometric measurements (weight, BMI, and waist circumference) and a statistically significant increase in the number of patients with normal cholesterol and LDL-cholesterol (p<0.001) were observed at two-month visit compared with first visit (p<0.001). The number of patients with normal triglyceride levels at final visit compared with first visit also increased significantly (p=0.04). A total of 186 (56.4%) patients had drug-related problems at first visit and 31 (9.4%) patients at two-month visit.

CONCLUSION

The implementation of a patient-centered weight management model had a positive impact on the improvement of anthropometric, clinical and therapeutic parameters.

The Impact of Direct-to-Consumer Pharmaceutical Advertising on Public Knowledge of Gastroesophageal Reflux Disease: A Study on Over-the-Counter Proton Pump Inhibitors

BACKGROUND

The use of direct-to-consumer advertising (DTCA) to promote sales of over-the-counter (OTC) pharmaceuticals used to manage common medical conditions, such as gastroesophageal reflux disease (GERD), is increasing. However, the educational value of these advertisements as well as the public perceptions of this type of advertising remain largely unknown among non-English speaking populations.

OBJECTIVE

The aim of this study was to explore the public perceptions and educational value of a short motion graphic video documenting the lifestyle of person with GERD and presenting a brief introduction to the role of proton pump Inhibitors (PPIs) in relieving the symptoms.

METHODS

This was a prospective quasi-experimental study in which a short mock advertising motion graphic video was shown to a sample of adult individuals in malls and shopping centers in different cities across Saudi Arabia. Participants were required to express their levels of agreement with six statements concerning their perceptions of DTCA of OTC drugs, and answer a quiz consisting of three questions and enquiries about their knowledge of GERD and the OTC drugs used in its treatment.

RESULTS

Two hundred and ninety-five participants were involved in this study, the majority of whom were female (55.30%). After watching the video, the percentages of participants who strongly agreed or agreed that DTCA is a credible source of information and encourages them to purchase the marketed drug have increased significantly (P<0.05). With regard to the quiz, the percentages of participants with correct answers regarding the definition of GERD, knowledge of OTC drugs for GERD, and awareness of the common side effects of PPIs increased from 81.69% to 95.93%, 69.83% to 96.27%, and 46.44% to 91.53%, respectively (P<0.0001).

CONCLUSION

DTCA of OTC drugs for GERD, particularly if the content complies with the regulatory requirements, can promote the public knowledge of the disease and treatment options.

Personal, academic and stress correlates of gastroesophageal reflux disease among college students in southwestern Saudi Arabia: A cross-section study

Background

Gastroesophageal reflux disease (GERD) is a worldwide prevalent gastrointestinal disorder which has negative impacts on quality of life, health and economy. The aims of this study were to assess the prevalence of GERD among college students in southwestern Saudi Arabia and to evaluate its personal, academic and stress correlates.

Materials and methods

Through a cross-sectional study design, a self-reported questionnaire was distributed between a representative sample of students in health and non-health care colleges in southwestern Saudi Arabia. The questionnaire included data for personal characteristics, academic study, and Arabic versions of GERD questionnaire (GerdQ) and Cohen's Perceived Stress Scale.

Results

Out of 2878 studied students, GERD was reported by 28.6% and 36.6% of students in health and non-health care colleges respectively with an overall prevalence rate of 33.18%. It was associated with impacts on daily life in 17.2% of students. By multivariable regression analysis, GERD was significantly higher among males (aOR = 1.44, 95% CI:117–1.65), ex-smokers (aOR = 1.87), current smokers (aOR = 1.71), non-health care students (aOR = 1.36) and those exposed to high perceived stress (aOR = 1.30).

Conclusion

GERD is a prevalent problem among college students in southwestern Saudi Arabia as it affects about one third of the students. Considering high prevalence of GERD, associated daily life impacts, young age of the studied subject and the risk of future complications, this condition could represent a challenging health and economic problem. The risk of GERD is higher among; males, smokers, former smokers, non-health care colleges students and subjects exposed to high perceived stress.

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GERD affects about one third of college students in southwestern Saudi Arabia.

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GERD is associated with daily life impacts in about one fifth of the students.

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GERD could represent a challenging health and economic problem.

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GERD is significantly associated with high perceived stress.

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Risk of GERD is higher among male students, smokers and non-health care students.