Antacids. Indications and limitations

A Randomized Double-blind Clinical Trial of Weierkang Pills for the Treatment of Chronic Atrophic Gastritis

BACKGROUND AND GOALS

There are currently no standard treatments for chronic atrophic gastritis and traditional Chinese medicine may be effective. This study aims to investigate the efficacy and safety of Weierkang pills in treating chronic atrophic gastritis.

MATERIALS AND METHODS

There were 108 patients in our study. They were randomly assigned to 2 groups. In group A, patients received Weierkang pills and patients in group B received folic acid combined with teprenone. Symptoms, endoscopic scores, and biopsy specimens were compared at baseline and 3 months after treatment. Meanwhile, the expressions of vascular endothelial growth factor and trefoil factor 3 (TFF3) in biopsy specimens were also compared.

RESULTS

Our study showed that the total effective rates of atrophy/intestinal metaplasia in group A reached the same level as group B (51.7% vs. 40.0%, P =0.419). Weierkang significantly improved the total effective rate of atrophy/intestinal metaplasia in gastric angle compared with group B (64.7% vs. 33.3%, P =0.024). Weierkang can significantly lower the total Kyoto risk score (2.6±1.1 vs. 3.3±1.0, P =0.002) and atrophy score (1.4±0.6 vs. 1.8±0.5, P =0.001) after treatment. In addition, Weierkang improves symptoms (1.3±1.3 vs. 2.3±1.8, P =0.003) and epigastric pain (0.2±0.4 vs. 0.5±0.6, P =0.041). The expression of TFF3 in gastric mucosa decreased significantly after treatment with Weierkang ( P =0.002).

CONCLUSIONS

Weierkang can improve the endoscopic appearance and pathologic changes of chronic atrophic gastritis patients. Symptoms also improved. TFF3 may be involved the pathophysiology mechanism.

Network Pharmacology Approach to Investigate the Mechanism of Modified Liu Jun Zi Decoction in the Treatment of Chronic Atrophic Gastritis

Although modified Liu Jun Zi decoction (MLD) has favorable outcomes for chronic atrophic gastritis (CAG) in clinics, the identification of its active ingredients and the molecular mechanism of pharmacology are still unknown and need to be solved urgently. In the study, we screened 170 active components of MLD based on oral bioavailability ≥30% and drug-likeness ≥0.18 via the TCMSP platform. We further establish a dataset containing 315 CAG targets from PharmGkb, GeneCard, OMIM, DrugBank database, and Therapeutic Target database. Network pharmacology found that there are 110 active components of MLD and 26 potential targets for CAG in the “ingredient-target” network. The results of gene ontology analysis show that these targets are involved mainly in reactive oxygen species metabolic process, regulation of vasculature development, and T cell activation. KEGG pathways analysis indicates that these signaling pathways in the treatment of CAG include HIF-1 signaling pathway, neurodegeneration-multiple diseases pathway, MAPK signaling pathway, and PI3K-Akt signaling pathway. Finally, docking of the active component quercetin and clinical medicine Omeprazole with the core targets was carried out. We found that quercetin, a crucial active ingredient in MLD, has good binding activity with potential targets of CAG, and its molecular conformation is stable, which is better than the binding energy of Omeprazole. So, the active ingredients of MLD exhibit good potential drugs for the treatment of CAG.

Antacids revisited: review on contemporary facts and relevance for self-management

Heartburn and acid regurgitation are the typical symptoms of gastroesophageal reflux. Despite the availability of several treatment options, antacids remain the mainstay treatment for gastroesophageal reflux-related symptoms based on their efficacy, safety, and over-the-counter availability. Antacids are generally recommended for adults and children at least 12 years old, and the FDA recommends antacids as the first-line treatment for heartburn in pregnancy. This narrative review summarizes the mechanism, features, and limitations related to different antacid ingredients and techniques available to study the acid neutralization and buffering capacity of antacid formulations. Using supporting clinical evidence for different antacid ingredients, it also discusses the importance of antacids as OTC medicines and first-line therapies for heartburn, particularly in the era of the COVID-19 pandemic, in which reliance on self-care has increased. The review will also assist pharmacists and other healthcare professionals in helping individuals with heartburn to make informed self-care decisions and educating them to ensure that antacids are used in an optimal, safe, and effective manner.

Review article: the management of heartburn during pregnancy and lactation

BACKGROUND

Gestational reflux is common, affecting up to 80% of pregnant women. Most symptoms will abate during lactation. During both of these periods, interventions used to relieve symptoms focus on a "step-up" methodology with progressive intensification of treatment. This begins with lifestyle modifications.

AIM

To provide guidance in the treatment of reflux in pregnancy and lactation, as well as briefly summarising the pathogenesis, clinical presentation and diagnostic workup.

METHODS

A comprehensive search, using online databases PubMed and MEDLINE, along with relevant manuscripts published in English between 1966 and 2019 was used. All abstracts were screened, potentially relevant articles were researched, and bibliographies were reviewed.

RESULTS

Only a small percentage of relevant drugs are contraindicated for use in pregnancy or while breastfeeding. However, not all drug agents have been extensively evaluated in pregnant women or during the breastfeeding period. Antacids, alginates, and sucralfate are the first-line therapeutic agents. If symptoms persist, any of the H₂ RAs can be used except for nizatidine (due to foetal teratogenicity or harm in animal studies). PPIs are reserved for women with intractable symptoms or complicated GERD; all are FDA category B drugs, except for omeprazole, which is a category C drug.

CONCLUSIONS

The management of heartburn during pregnancy and lactation begins with lifestyle modifications. In situations where disease severity increases, medical providers must discuss risks and benefits of these medicines with the patient in detail.

Gastrointestinal diseases during pregnancy: what does the gastroenterologist need to know?

Pregnancy is characterized by numerous physiological changes that may lead to a diversity of symptoms and frequently to gastrointestinal complaints, such as heartburn, nausea and vomiting, or constipation. Chronic gastrointestinal diseases require treatment maintenance during this period, raising the challenging question whether outcomes beneficial to the mother may be harmful for the fetus. In addition, certain diseases, such as acute fatty liver of pregnancy, only develop during pregnancy and may require urgent procedures, such as fetus delivery. Even though they are not present in our day-to-day practice, knowledge of pregnancy-related diseases is fundamental and collaboration between gastroenterologists and obstetricians is often necessary. Herein, we review pregnancy-related diseases and systematize the most appropriate treatment choices according to the recent literature and guidelines, so that the article can serve as a guide to the gastroenterologist regarding the medical approach to pregnancy-related gastrointestinal and liver diseases and their therapeutic management.

Chinese Classical Formula Sijunzi Decoction and Chronic Atrophic Gastritis: Evidence for Treatment Approach?

Objective

This aim is to evaluate the effect of Sijunzi decoction (SJZD) treating chronic atrophic gastritis (CAG).

Methods

We performed searches in seven databases. The randomized controlled trials (RCTs) comparing SJZD with standard medical care or inactive intervention for CAG were enrolled. Combined therapy of SJZD plus conventional therapies compared with conventional therapies alone was also retrieved. The primary outcome included the incidence of gastric cancer and the improvement of atrophy, intestinal metaplasia, and dysplasia based on the gastroscopy and pathology. The secondary outcomes were Helicobacter pylori clearance rate, quality of life, and adverse event/adverse drug reaction.

Results

Six RCTs met the inclusion criteria. The research quality was low in the trials. For the overall effect rate, pooled analysis from 4 trials showed that modified SJZD plus conventional medications exhibited a significant improvement (OR = 4.86; 95% CI: 2.80 to 8.44; P < 0.00001) and without significant heterogeneity compared with the conventional medications alone. None reported the adverse effect.

Conclusions

Modified SJZD combined with conventional western medicines appears to have benefits for CAG. Due to the limited number and methodological flaw, the beneficial and harmful effects of SJZD for CAG could not be identified. More high-quality clinical trials are needed to confirm the results.

Efficacy of alginate-based reflux suppressant and magnesium-aluminium antacid gel for treatment of heartburn in pregnancy: a randomized double-blind controlled trial

The aim of this study was to compare the therapeutic efficacy of alginate-based reflux suppressant and magnesium-aluminium antacid gel for treatment of heartburn in pregnancy. A double-blinded, randomized, controlled trial was conducted. One hundred pregnant women at less than 36 weeks gestation with heartburn at least twice per week were randomized to either alginate-based reflux suppressant or to magnesium-aluminium antacid gel. Details of heartburn were recorded before beginning the treatment and the second week of study. Primary outcome measure was the improvement of heartburn frequency after treatment and secondary outcome were the improvement of heartburn intensity, quality of life, maternal satisfaction, maternal side effects, pregnancy and neonatal outcomes. There was no difference between treatment and control groups in improvement of heartburn frequency (80% vs 88%, p = 0.275), 50% reduction of frequency of heartburn (56% vs 52%, p = 0.688), improvement of heartburn intensity (92% vs 92%, p = 1.000) and 50% reduction of heartburn intensity (68% vs 80% cases, p = 0.075). There were also no significant differences in quality of life, maternal satisfaction, maternal side effects, pregnancy and neonatal outcomes. Alginate-based reflux suppressant was not different from magnesium-aluminium antacid gel in the treatment of heartburn in pregnancy.

Management of gastrointestinal and liver diseases during pregnancy

In the majority of patients with chronic gastrointestinal and liver diseases, maintenance therapy is required during pregnancy to control the disease, and disease follow-up or disease control might necessitate endoscopy. Evidence on the safety of drugs and imaging techniques during pregnancy is scarce and sometimes difficult to interpret. In this review we summarise existing literature with the aim of optimising counselling of patients with common chronic gastrointestinal and liver diseases who want to conceive.

Gastroesophageal reflux disease in pregnancy

Gastroesophageal reflux disease during pregnancy is common. Altered structure and function of the normal physiological barriers to reflux of gastric contents into the oesophagus explain the high incidence of this problem in pregnant women. For the majority of patients, life-style modifications are helpful, but are not sufficient to control symptoms and medication is required. The optimum management of reflux in pregnant patients requires special attention and expertise, since the safety of the mother, foetus and neonate remain the primary focus. Gastroenterologists and obstetricians should work together to optimise treatment. Typically, one utilises a step-up program that starts with life-style modifications and antacids. If those methods fail, histamine-2 receptor antagonists and proton pump inhibitors are tried. Rarely, promotility agents are used. Initiation of these medications must be undertaken after a careful discussion of risks and benefits with patients. In patients without a prior history of reflux, symptoms usually abate after delivery.

Gastrointestinal medications in pregnancy

Management of the pregnant patient presents unique challenges to the treating physician. Current Food and Drug Administration classifications do not necessarily reflect clinical experience or recent literature. Ideally, one should use the lowest-risk drug possible, with attention to the appropriate level of efficacy for the patient's condition, the stage of pregnancy and dose adjustment. Every treatment decision should be fully discussed with the patient and a multidisciplinary team that should include the obstetrician and, if appropriate, the paediatrician. This review will cover the medications commonly used to treat gastrointestinal disease. The majority of medications can be categorised as 'low risk' or 'should be avoided'. The following medications should never be used during pregnancy due to the clear risk of teratogenicity or adverse events: bismuth, castor oil, sodium bicarbonate, methotrexate, ribavirin, doxycycline, tetracycline, and thalidomide.

The safety of pharmacological therapies for gastrointestinal conditions encountered during pregnancy

Properly assessing the safety of pharmacological therapies for gastrointestinal conditions encountered during pregnancy is a challenge on account of both the often limited controlled data available and the potentially confounding effect of the underlying disorders requiring treatment on fetal outcomes. Here, the available data with regard to gastrointestinal disorders specific to pregnancy, those that may be precipitated or exacerbated by pregnancy and those that may be pre-existing or arise concurrently during pregnancy are reviewed.

American gastroenterological association institute technical review on the use of gastrointestinal medications in pregnancy

This literature review and the recommendations therein were prepared for the American Gastroenterological Association Institute Clinical Practice and Economics Committee. The paper was approved by the Committee on February 22, 2006 and by the AGA Institute Governing Board on April 20, 2006.

Review article: the management of heartburn in pregnancy

Heartburn is a normal consequence of pregnancy. The predominant aetiology is a decrease in lower oesophageal sphincter pressure caused by female sex hormones, especially progesterone. Serious reflux complications during pregnancy are rare; hence upper endoscopy and other diagnostic tests are infrequently needed. Gastro-oesophageal reflux disease during pregnancy should be managed with a step-up algorithm beginning with lifestyle modifications and dietary changes. Antacids or sucralfate are considered the first-line drug therapy. If symptoms persist, any of the histamine2-receptor antagonists can be used. Proton pump inhibitors are reserved for women with intractable symptoms or complicated reflux disease. All but omeprazole are FDA category B drugs during pregnancy. Most drugs are excreted in breast milk. Of systemic agents, only the histamine2-receptor antagonists, with the exception of nizatidine, are safe to use during lactation.

Calcium intake during pregnancy among white and African-American pregnant women in the United States

OBJECTIVE

To characterize the calcium intake in a racially mixed cohort of pregnant women, including the contribution of supplementation and antacids.

METHODS

A cohort of women was interviewed twice during their pregnancies. The interviews included a food frequency questionnaire and questions on calcium supplementation and antacid intake. Pregnant women seeking prenatal care at a Pittsburgh hospital in the first trimester were enrolled. 454 women were enrolled and did not miscarry; 385 completed two interviews and were of white or African-American race.

RESULTS

Mean and median intakes of calcium were 1671 mg/day and 1482 mg/day. 36% of the women were under the former RDA level (1200 mg/day) for calcium, while 26% were under the current AI (1000 mg/day). Six percent were taking in less than 600 mg/day, and 15% over 2500 mg/day, the tolerable upper limit. Young women were particularly likely to have low intakes (12% of those less than 21 years of age had less than 600 mg/day). Black women were slightly overrepresented among those with low intake (8% vs. 5% of whites), but, overall, their intake was quite similar to whites. Milk and cheese provided more calcium than other food items. Many women took antacids, especially during the second half of pregnancy, and these were a major source of calcium for some members of the cohort.

CONCLUSIONS

Although mean and median calcium intake in the cohort were above the AI, many women had calcium intakes that were too high or low. Dairy products provided the most calcium for most pregnant women, and antacids were an important source for many.

Application of a data-mining technique to analyze coprescription patterns for antacids in Taiwan

BACKGROUND

Although antacids are popular drugs with a long history of use, their true utilization patterns-including over-the-counter use-have rarely been documented. Because all antacids are reimbursed under the National Health Insurance program in Taiwan, it is possible to access and analyze nationwide data for these drugs.

OBJECTIVES

The purposes of this study were to estimate the scale of antacid prescribing in Taiwan using the national insurance claims for outpatient services and to analyze coprescribing patterns of antacids using modern data-mining techniques.

METHODS

The National Health Insurance Research Database in Taiwan supplied the visit-based sampling data sets, which had a sampling ratio of 0.2% for all claims for outpatient medical services in the year 2000. In addition to the plain statistics (ie, data from simple calculations) for antacid prescriptions, we also analyzed relationships between prescriptions for antacids and nonantacid drugs. A data-mining technique-association rule mining-was applied to identify the drugs prescribed in combination with antacids.

RESULTS

Among a total of 409,049 eligible prescriptions for 1,704,595 drug items to be administered orally, antacids were present in 213,494 prescriptions (52.2%). Antacid users were generally older than nonusers (mean [SD] age, 39.9 [23.4] years vs 32.4 [25.7] years). In all, 88.8% of antacid items (189,531/213,494) were prescribed without claims diagnoses of gastrointestinal disorders. Using association rule mining with a 1.0% minimum support factor, there were 36 strong association rules between prescriptions for antacids and other drug subgroups at the third level of Anatomical Therapeutic Chemical classification. Nonsteroidal anti-inflammatory drugs and drugs for treating upper respiratory infections played dominant roles in the associations with antacid prescriptions; vitamin B complex and antivertigo preparations were also strongly associated with antacids.

CONCLUSIONS

Antacid coprescriptions were common in Taiwan in the year 2000. Further study should investigate whether antacid prescribing patterns are influenced by Taiwanese perceptions that Western drugs injure the stomach.

Gastroesophageal reflux disease during pregnancy

Approximately two thirds of pregnant patients develop heartburn. The origin is multifactorial, but the predominant factor is a decrease in LES pressure caused by female sex hormones, especially progesterone. Mechanical factors play a small role. Serious reflux complications during pregnancy are rare; therefore EGD and other diagnostic tests are infrequently needed. Symptomatic GERD during pregnancy should be managed with a step-up algorithm beginning with lifestyle modifications and dietary changes. Antacids or sucralfate are considered the first-line medical therapy. If symptoms persist, H2RAs should be used. Ranitidine is probably preferred because of its documented efficacy and safety profile in pregnancy, even in the first trimester. Proton-pump inhibitors are reserved for the woman with intractable symptoms or complicated reflux disease. Lansoprazole may be the preferred PPI because of its safety profile in animals and case reports of safety in human pregnancies.

Gastric and duodenal ulcers during pregnancy

The frequency, symptoms, and complication rate of PUD seem to decrease during pregnancy. Yet clinicians often have to treat dyspepsia or pyrosis of undetermined origin during pregnancy because the frequency of pyrosis significantly increases during pregnancy, and clinicians reluctantly perform EGD during pregnancy for pyrosis to differentiate reliably between GERD and PUD. Dyspepsia or pyrosis during pregnancy is initially treated with dietary and lifestyle modifications. If the symptoms do not remit with these modifications, sucralfate or antacids, preferably magnesium-containing or aluminum-containing antacids, should be administered. Histamine2 receptor antagonists are recommended when symptoms are refractory to antacid or sucralfate therapy. Ranitidine seems to be a relatively safe H2 receptor antagonist. If symptoms continue despite H2 receptor antagonist therapy, the patient should be evaluated for possible EGD or PPI therapy. Pregnant women with hemodynamically significant upper gastrointestinal bleeding or other worrisome clinical findings should undergo EGD. Indications for surgery include ulcer perforation, ongoing active bleeding from an ulcer requiring transfusion of six or more units of packed erythrocytes, gastric outlet obstruction refractory to intense medical therapy, and a malignant gastric ulcer without evident metastases.

Use of antacids in a general population: the impact of health-related variables, lifestyle and sociodemographic characteristics

Self-medication with antacids is very common in patients with less severe forms of dyspepsia, but we know very little about the users of antacids and their incentive to take them. The aim of this study was to analyze the relationship between self-reported use of antacids and health-related variables, lifestyle, and sociodemographic characteristics in order to characterize the use of antacids in a general population. The use of antacids was assessed by a questionnaire answered by men and women aged 20-62 years (n = 15,986; response rate 75.9%). Logistic regression analysis was used to quantify the relationships between the use of antacids and health-related variables, lifestyle, and sociodemographic characteristics. Approximately 10% of the population had used antacids during the preceding 14 days. There was no overall gender difference. Among those who had no dyspeptic symptoms, 1.5% reported use of antacids, whereas among those who had all three dyspeptic symptoms (heartburn, epigastric pain, peptic ulcer), 46.5% had used antacids. Heartburn was the most important predictor for antacid use in both men (odds ratio [OR] = 8.57 [6.65-11.04]) and women (OR = 9.35 [7.16-12.221) followed by self-reported epigastric pain and peptic ulcer (both: OR = approximately 2). The importance of these self-reported health conditions remained unchanged after adjusting for lifestyle and sociodemographic variables. There were fewer antacid users among unmarried women than married women, and coffee-drinking was inversely associated with antacid use. These findings were consistent in both bivariate and multivariate analysis. The present study provides population-based information showing that self-medication with antacids in Norway appeared to be appropriate. Because dyspeptic symptoms play a major role in the consumption of antacids, this study shows the importance of including information about specific clinical variables in the analysis and interpretation of patterns of drug use.

Treating gastro-oesophageal reflux disease during pregnancy and lactation: what are the safest therapy options?

Gastro-oesophageal reflux and heartburn are reported by 45 to 85% of women during pregnancy. Typically, the heartburn of pregnancy is new onset and is precipitated by the hormonal effects of estrogen and progesterone on lower oesophageal sphincter function. In mild cases, the patient should be reassured that reflux is commonly encountered during a normal pregnancy: lifestyle and dietary modifications may be all that are required. In a pregnant woman with moderate to severe reflux symptoms, the physician must discuss with the patient the benefits versus the risks of using drug therapy. Medications used for treating gastro-oesophageal reflux are not routinely or vigorously tested in randomised, controlled trials in women who are pregnant because of ethical and medico-legal concerns. Safety data are based on animal studies, human case reports and cohort studies as offered by physicians, pharmaceutical companies and regulatory authorities. If drug therapy is required, first-line therapy should consist of nonsystemically absorbed medications, including antacids or sucralfate, which offer little, if any, risk to the fetus. Systemic therapy with histamine H2 receptor antagonists (avoiding nizatidine) or prokinetic drugs (metoclopramide, cisapride) should be reserved for patients with more severe symptoms. Proton pump inhibitors are not recommended during pregnancy except for severe intractable cases of gastrooesophageal reflux or possibly prior to anaesthesia during labour and delivery. In these rare situations, animal teratogenicity studies suggests that lansoprazole may be the best choice. Use of the least possible amount of systemic drug needed to ameliorate the patient's symptoms is clearly the best for therapy. If reflux symptoms are intractable or atypical, endoscopy can safely be performed with conscious sedation and careful monitoring the mother and fetus.

Gastric and duodenal ulcers during pregnancy

The frequency, symptoms, and complication rate of peptic ulcer disease appear to decrease during pregnancy significantly. Clinicians, however, often have to treat dyspepsia or pyrosis of undetermined cause because the frequency of pyrosis increases during pregnancy. Physicians are reluctant to perform esophagogastroduodenoscopy (EGD) during pregnancy for pyrosis to reliably differentiate gastroesophageal reflux from peptic ulcer disease. Dyspepsia or pyrosis during pregnancy first should be treated with dietary and lifestyle changes, together with antacids or sucralfate. When symptoms persist, H2 receptor-antagonists are recommended. If symptoms continue and are severe despite these interventions, the patient should be evaluated for possible EGD or proton pump inhibitor therapy during the second or third trimester.