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Medication

There are 4 major classes of drugs to treat the acid element of acid reflux.
In ascending order of effectiveness, they are antacids, alginates, H2 blockers and Proton Pump Inhibitors.

If you need to use any of these drugs frequently,
please seek medical advice.









Antacids

They work immediately on excess acid. They do not prevent excess acid occurring.
These are drugs that neutralise the acid. Most commonly they are made of chalk, calcium carbonate. Examples are Tums or Rennie. Chemically, this reaction takes place:
CaCO3 + 2HCl → CaCl2 + H2O + CO
(Calcium Carbonate + Hydrochloric acid gives Calcium Chloride (a harmless salt) plus water and carbon dioxide).


Alginates

Gaviscon is the brand name of the white milky liquid that floats on the stomach contents as oil floats on water to reduce the possibility of reflux whilst also providing a temporary protective film to the lower oesophagus and neutralising the acid with an antacid component. (Some generic versions are now available.)
 NHS cost for
28 days
(2011)
 Gaviscon £5.84


H2 blockers

Histamine H2 Receptor Antagonists work to block the (histamine H2) signals that tell the stomach to produce acid. (N.B. This is not the same as an antihistamine which blocks histamine H1).
The most common is Ranitidine, brand name Zantac but others are available as shown below.
These work proactively to reduce the amount of acid rather than being an instant antacid. Often prescribed to be taken in the evening to reduce nighttime reflux of acid.

H2 blockers
 Generic name Brand name Dose *NHS  cost for
28 days 
(2011)
 Ranitidine Zantac 150 mg
 300 mg
 £1.35
 £1.28
 Famotidine Pepsid 40 mg £4.68
 Cimetidine Tagamet 400 mg £6.27
 Nizatidine Axid 300 mg £9.81
  • (Other H2 blockers: Lafutidine, Loxtidine, Niperotidine, Roxatidine.)

* Please note doses shown are not guaranteed to be equivalent. Do not assume because a dose is shown it is the safe dose. It may vary according to age and body build.

Proton Pump Inhibitors (PPIs)

These are the most effective drugs to reduce acid production. They work by effectively stopping the production of some of the cells (proton pumps) that produce acid in the stomach.
There are a number known by different names as shown in the table below. The equivalent dose shown is the "maintenance dose" though you may be prescribed a higher dose initially. They are proactive drugs and are most effective after taking them for a few days. They do not neutralise acid already produced.

PPI (Proton Pump Inhibitor) drugs

Generic name

UK brand name

US brand name

Equivalent dose (approx)

NHS  cost for 28 days (2011)

Omeprazole

Losec

Prilosec

20 mg

£1.68

Lansoprazole

Zoton

Prevacid

30 mg

£2.08

Pantoprazole

Protium

Protonix

40 mg

£16.43

Rabeprazole

Pariet

Aciphex

20 mg

£19.55

Esomeprazole

Nexium

Nexium

20 mg

40mg *

£18.50

£25.19

Dexlansoprazole

Dexilant

Kapidex / Dexilant

30 mg

N/A


        (Other PPIs: Ilaprazole, Picoprazole, Tenatoprazole, Timoprazole)

Do not assume because a dose is shown it is the safe dose. It may vary according to age and body build.

The most common brand names are shown though they may also be known under other names in other parts of the world.

Research evidence has shown all PPIs are as effective as each other (though the drugs companies may try to make us believe otherwise) but some may be better tolerated by some patients. [a-iv][a-v]

* Astra Zeneca (who make the drug) claims 40mg esomeprazole is equivalent to 20mg omeprazole and one (Astra Zeneca sponsored) trial showed 40mg esomeprazole was better at reducing acid production than 20mg omeprazole. [a-vi]
Another study published February 2015 [a-vii]  also compared 40mg esomeprazole with 30mg lansoprazole and 40mg Pantoprazole finding: "esomeprazole was more effective".

Research funded by Reckitt Benkiser (who make the drug) found Gaviscon was no less effective than standard dose omeprazole for a 24hr period. [a-viii]

Controversy over long term medication

The efficacy of long term use of acid suppressant medication (particularly PPIs) has been questioned with some claiming they cause oesteoporosis, hypermagnesaemia, and even cancer. Whereas these claims are not entirely unfounded, the evidence is disputed. (See "hypochlorhydria" and "Myths and Misconceptions")

PPIs have been linked to Myocardial Infarction [a-ix]. That those with heart conditions may be greater amongst those taking PPIs is not surprising since the symptoms of heart attack and indigestion can be so similar. The "evidence" shows a correlation not a causation.

A more recent study [a-x] followed 54,422 GERD patients in Taiwan compared with 269,572 randomly selected age-, gender-, comorbidity-matched subjects, finding, amongst other things, "patients who were prescribed PPIs for more than one year had slightly decreased the risk of developing Acute Myocardial Infarction".
  
https://sites.google.com/site/barrettswessex/treatment/drugs/ppi-dangers/Umbrella%20meme.png

Similarly PPIs have been associated with Chronic Kidney Disease [a-xi]. Again this showed a correlation: those with kidney problems are more likely to be users of PPIs.

Another study looking at the medicines used by patients over the age of 75 with dementia, found a higher proportion of them used PPIs than amongst the general population. [a-xii] Another case of correlation rather than causation and some doctors were led to speak out about misinterpreting the data. [a-xiii.]

A paper published in Gastroenterology in June 2017 [a-xiv], however, found no association between the use of proton pump inhibitors and the risk for mild cognitive impairment, dementia and Alzheimer’s disease

Another paper published in 2013 appeared to show PPIs could cause oesophageal cancer [a-xv].
This quickly received rebuffs: [a-xvi.]

https://sites.google.com/site/barrettswessex/treatment/drugs/ppi-dangers/PPI%20Scales.jpg
The popular media loves scare stories like these and, never letting the facts get in the way of a good story, can exaggerate them causing real fear amongst some PPI users who often try turning to unproven "natural" remedies for their condition that may do more harm than good.

A Danish study in 2014 had concluded: "No cancer-protective effects from PPI's were seen. In fact, high-adherence and long-term use of PPI were associated with a significantly increased risk of adenocarcinoma or high-grade dysplasia." [a-xvii] in contradiction of a 2013 study which concluded: "The use of PPIs is associated with a decreased risk of OAC and/or BO-HGD in patients with BO. None of the studies showed an increased risk of OAC." [a-xviii] and an article published in 2014 which claimed a protective effect for PPIs. [a-xix]

There has been research however that shows PPIs most probably have a chemo-protective effect helping reduce incidences of oesophageal cancer as published in a 2014 meta-analysis [a-xx] finding "PPI use was associated with a 71% reduction in risk of OAC and/or BO-HGD in patients with BO."

Another paper, "PPIs display antitumor effects in Barrett's adenocarcinoma [a-xxi]" also found "evidence supporting the potential use of PPIs as novel antineoplastic drugs for EAC".

The 2014 NICE guidelines on the management of GORD [a-xxii] made the recommendation to Consider laparoscopic fundoplication for people who have:

  • a confirmed diagnosis of acid reflux and adequate symptom control with acid suppression therapy, but who do not wish to continue with this therapy long term

  • a confirmed diagnosis of acid reflux and symptoms that are responding to a PPI, but who cannot tolerate acid suppression therapy.
An Option Grid produced by NICE may be found in the Appendices.

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