PHC 576

GASTROESOPHAGEAL REFLUX DISEASE

(GERD/GORD)

DR NORKASIHAN IBRAHIM
Principal Lecturer
Deartment of Pharmacy Practice
Faculty of Pharmacy UiTM
Learning outcomes
• Identify and assess the primary medical and pharmaceutical problems
in GERD. (C4)
• Identify the therapeutic goals and to recommend therapeutic
alternatives to problems related to pharmaceutical interventions of
GERD. (C5)
• Assess the effectiveness of the pharmaceutical interventions by using
appropriate monitoring parameters to achieve the desired outcome.
(C6)

NKI/ PHC576/ MARCH2021

“Saya selalu rasa pedih ulu hati
selepas makan. Patut tak saya buat
OGDS screening?” En. Buncit/48yo

Complaints of heartburn 2-3x/week over the last

4 months; has episodes of regurgitation which
left with acidic taste in his mouth; disturbed sleep
2 nights/week.

DM, HTN - 5 years (Mixtard 15u BD; Amlodipine

10mg OD)
CKD stage 3 - 2 years
Gastritis – 4 month (OTC Gaviscon 15ml nocte)
DISEASES OF THE LOWER GIT
DISEASES OF THE UPPER
Constipation - nerve cells in the GIT
esophagus degenerate for unknown
reasons
Achalasia - nerve cells in
Inflammatory Bowel Disease (IBD) – the esophagus
Crohn’s disease & Ulcerative colitis degenerate for unknown
reasons
Irritable Bowel Syndrome (IBS) – long
term gastrointestinal disorder that can Dyspepsia - indigestion
cause persistent discomfort Gastroparesis – stomach
paralysis
Hemorrhoids – swelling of the veins in
the anus or rectum (triggers: overweight,
constipation, heavy lifting, or pregnancy) GERD – stomach acid
travels up into the
Celiac disease – autoimmune reaction stomach
in the small intestine (gluten sensitivity)

Colon polyps & cancer – refer notes

PHC551
• DEFINITION
• EPIDEMIOLOGY
• ETIOLOGY
• RISK FACTORS
• CLASSIFICATION
• CLINICAL MANIFESTATION
• DIAGNOSTIC EVALUATION
• TREATMENT
• COMPLICATIONS
 GLOBAL DEFINITION
The Montreal definition & classification of GERD

• A condition which results from the recurrent backflow of gastric

contents into the esophagus and adjacent structures causing
troublesome symptoms and/or tissue injury.
• “troublesome” from patient’s perspective
• mild symptoms occurring >1 day/week
• moderate/severe symptoms2 days/week
 Sphincter relaxes after swallowing and Sphincter relaxes after swallowing BUT does not/
contracts (closes) to prevent food & acid move partial contracts. The amount of acid reflux
into esophagus required to cause GERD varies from person to
person.
A hiatal hernia is when your stomach bulges up
into your chest through an opening in your
diaphragm, the muscle that separates the two
areas. The opening is called the hiatus, so this
condition is also called a hiatus hernia.
 EPIDEMIOLOGY

• Common around the

world with different
prevalence
• Western 10 – 20%
• Asian 2.3 – 6.2%

Hye-Kyung Jung. Epidemiology of GERD in Asia: A systematic review. J Neurogastroenterol Motil 2011;17:14-27
ETIOLOGY
• transient relaxation of the lower esophageal sphincter (LES)
• pressure abnormalities in the lower esophageal sphincter (which can
be caused by hormonal and neural mediators, food, drugs and patient
lifestyle)
• poor esophageal clearance
• delayed gastric emptying time
• hiatal hernia
RISK FACTORS
• Age and male sex - associated with a higher incidence of esophagitis
• Obesity - 2.5x more likely to have GERD than those with normal body mass
index (BMI); overweight and obesity contribute to the increasing
prevalence of GERD in the Asia-Pacific region
• In an Asian study, a BMI of >25 was a significant risk factor for GERD
• Alcohol
• Smoking
• Hiatus hernia - presence and size of a hiatal hernia are associated with a
more incompetent LES, defective peristalsis, increased acid exposure and
more severe mucosal damage
• Coffee, chocolate, fatty foods
• Acidic foods (e.g. spicy foods, citrus, carbonated drinks)
CLASSIFICATION
endoscopy does not add
value to the treatment
outcome nor influence
patients’ QoL

Chest pain not

associated with
cardiac events
CLINICAL MANIFESTATION
TYPICAL SYMPTOMS
ATYPICSL SYMPTOMS
Typical symptoms
The cardinal symptoms of GERD; may be worsened in a supine position, on bending, and while straining
(especially after a large or fatty meal) and may be temporarily relieved by antacids.

• Heartburn: burning sensation in the retrosternal region (49%)

• Heartburn + hoarseness common in men with erosive esophagitis

• Regurgitation: perception of flow of refluxed gastric contents into the mouth or hypopharynx (42%)
• Common in women

• Water brash (hypersalivation)

• Epigastric pain

• Sleep disturbance: 18% - 25% of respondents in surveys; substantially improved by PPI therapy or antireflux
surgery
Atypical symptoms
• Nausea, eructation (belching)
• slow digestion, early satiety, epigastric pain, bloating, vomiting, and
chest pain
• Extraesophageal symptoms: dry cough, wheeze, chronic
rhinosinusitis, hoarseness, pharyngeal pain, and globus, as well as
early awakening, nocturnal awakening, and nightmares.
Alarming symptoms (warrant prompt
investigation, usually beginning with urgent
endoscopy.)
• Dysphagia • family history of esophageal
• Odynophagia adenocarcinoma
• weight loss • nocturnal choking
• Anemia • abdominal mass
• Hematemesis • recurrent/frequent vomiting
• chest pain (should undergo an
appropriate cardiovascular risk
stratification before initiating
empiric PPI therapy)
“Saya selalu rasa pedih ulu hati
selepas makan. Patut tak saya buat
OGDS screening?” En. Buncit/48yo

Complaints of heartburn 2-3x/week over the last

4 months; has episodes of regurgitation which
left with acidic taste in his mouth; disturbed sleep
2 nights/week.

DM, HTN - 5 years (Mixtard 15u BD; Amlodipine

10mg OD)
CKD stage 3 - 2 years
Gastritis – 4 month (OTC Gaviscon 15ml nocte)
COMPLICATIONS
• Erosive esophagitis (EO)  Responsible for
40 – 60% of GERD symptoms
• Esophageal stricture  result from healing
EO
• Barret’s esophagus  squamous epithelia
lining of the esophagus by columnar
epithelium associated with
adenocarcinoma
• Peptic Ulcer Disease (PUD) or ulcers of the
esophagus or stomach.
DIAGNOSTIC EVALUATION
• Diagnostic tests  refer page 4&5 in
https://www.hopkinsmedicine.org/gastroenterology_hepatology/_pdfs/esophag
us_stomach/gastroesophageal_reflux_disease.pdf

• A clinical diagnosis of GERD can be made if the typical symptoms of acid

regurgitation and/or heartburn are present.

• Upper endoscopy is not necessary to make a diagnosis of GERD. It can be

considered in the following conditions:
• presence of alarm features/ onset of new alar features
• with risk of Barrett’s oesophagus (BE)
• Unsatisfactory treatment outcome from pharmaceutical interventions
TREATMENT GOALS
• Relief of symptoms
• Healing of esophagitis
• Prevention of recurrence and complications
• Improvement of quality of life
TREATMENT OPTIONS
1. Lifestyle modifications
2. Pharmacological interventions
• Empirical therapy
• Maintenance therapy
• Adjunctive therapy
• Refractory
3. Non-pharmacological interventions
• Anti-reflux surgery
• Endoluminal treatments: titanium beads implantation and full-thickness
plication, intend to reduce acid reflux episodes or transient lower esophageal
sphincter relaxations and increase LES basal pressure. Currently performed in
clinical trials as durable long-term benefits have not been shown
Lifestyle changes
• Refer page 6 in
https://www.hopkinsmedicine.org/gastroenterology_hepatology/_pd
fs/esophagus_stomach/gastroesophageal_reflux_disease.pdf
 PHARMACOTHERAPY IN GERD
Medications for Buncit’s GERD therapy?
Buncit/ 48yo
Dx: GERD
Rx:
Mixtard 15u BD x 2/12
Amlodipine 10mg OD x 2/12
OTC Gaviscon 15ml nocte x 2/52
 PPIs
Irreversibly binding the gastric acid
pump (i.e., the H+K+ATPase pump)
H2rA of the parietal cells  Blocks acid
secretion
BlockH2 receptors of the gastric - superiority over H2RAs for the
parietal cells blocks signals of treatment of reflux and erosive
Antacid acid production in the stomach
- an option in patients who have
esophagitis
- Initial treatment OD, step up BD
Neutralize/ buffer stomach acid.
symptoms of GERD but do not - 30 to 60 minutes prior to the first
- mild reflux <1/week suffer from erosive esophagitis
- not be a first-line recommendation meal of the day to assure maximum
- may develop tolerance with a efficacy
for the treatment of GERD
decreased efficacy observed after 3 - Nonresponders of maximal PPI
- No healing properties
to 4 weeks of treatment therapy may require surgical
- After meal, nocte evaluation.
- Disadvantages Clostridium-
PPIs failure: compliance, improper dosing timing, weakly acidic reflux, difficile–associated diarrhea,
delayed gastric emptying, nocturnal reflux, residual acid reflux, pneumonia, bone fractures,
rebound hypersecretion,
esophageal hypersensitivity, and reduced PPI bioavailability.
hypomagnesemia, vitamin
B12 deficiency, and possible drug
interactions
US Pharm. 2016;41(12):24-29.
Consider H2rA in mild
cases & step up to PPI if
unsatisfactory
 PPIs are preferred over H2rA
• more effective to relief symptoms
and prevent erosion.
• most effective for maintenance
therapy in reflux esophagitis

PPIs OD 30 to 60 minutes before

the first meal of the day at
standard doses x 8/52
H2rA nocte can be added to PPI
therapy
Use the lowest safest dose in
long term treatment

Armstrong D, Collins A, Talar-Wojnarowska R, Małecka-Panas E. Gastroesophageal Reflux Disease

(GERD). McMaster Textbook of Internal Medicine. Kraków: Medycyna Praktyczna.
https://empendium.com/mcmtextbook/chapter/B31.II.4.2. Accessed March 09, 2021.
Fig 1: Current
treatment
algorithm in
rGERD.

Before rGERD can

be considered,
one should
ensure that the
PPI regimen is
adequately
dosed and timed,
that patient
compliance with
the regimen is
confirmed, and
that symptoms
are typical of
GERD (heartburn
and/or
regurgitation)
and are not
located in the
epigastrium
(dyspepsia)
or in the throat
area.
rGERD – persistence of typical symptoms (heartburn and/or regurgitation) that do not
respond to a stable double dose of a PPI during a treatment period of at least 12 weeks
Buncit/ 48yo 2 week later….
Dx: GERD
“Mula-mula makan ubat ni
(Ranitidine) rasa ok, tapi lepas 3
Rx: minggu macam kurang berkesan”
Mixtard 15u BD x 2/12
Amlodipine 10mg OD x 2/12 1) Explain WHY??
Ranitidine 150mg OD x 8/52 2) Is Buncit having refractory
Magnesium trisilicate 15ml TDS/PRN GERD?

3) How would you optimise his

therapy?