Treatment

  Treatment Guidelines / Gastroesophageal Reflux Disease (GERD) Overview / Treatment

Treatment

Pharmacological Therapy


Treatment Goals:
  • Relief of symptoms
  • Healing of esophagitis
  • Prevention of recurrence & complications
  • Current consensus is that for patients w/ uncomplicated reflux symptoms, empiric therapy is the appropriate initial management

1. Empiric Therapy
  • Patients presenting w/ typical symptoms of GERD in the absence of long-standing, frequently recurring, progressive alarm symptoms or complicated disease may be started on empiric treatment w/o further investigation
  • Acid suppressive therapy is currently the mainstay of treatment for symptom relief in GERD in both acute & long-term treatment
    • Proton pump inhibitor is the drug of choice & recommended as initial therapy because of its superior safety
    • Patients w/ chest pain or GERD-related NCCP should have a thorough initial cardiac evaluation prior to starting empiric therapy
  • Short course therapy is effective in GERD patients treated empirically & duration varies from 2-8 wk
    • Should be tried for 2 wk for patients w/ typical GERD symptoms
    • Patients who present w/ atypical or extraesophageal manifestations take a longer time to respond to empiric therapy & often require twice-daily dosing for at least 12 wk

1.1. Proton Pump Inhibitors (PPIs)
  • Eg Dexlansoprazole, Esomeprazole, Lansoprazole, Omeprazole, Pantoprazole, Rabeprazole
  • Most potent type of acid suppressants
    • Provide most rapid symptom relief & heal esophagitis in the highest proportion of patients
    • Cornerstone of therapy for erosive esophagitis when given at standard dose once daily for 8 wk 
  • Recommended for both moderate & severe GERD & its complications
  • PPIs are substituted benzimidazoles that irreversibly bind the H+ K+ ATPase, the final step in gastric acid secretion
  • Should be given 30-60 min prior to meals to give PPIs time to interact w/ an activated pump
    • Dexlansoprazole can be taken w/ or w/o food
  • On-demand therapy w/ PPI is used where symptom control is the primary objective (eg patients w/ esophageal GERD syndrome w/o esophagitis)
  • Continuous therapy w/ PPI is recommended to maintain a healed mucosa, preventing recurrence of symptoms (eg in patients w/ erosive esophagitis)
  • Generally well tolerated; side effects reported were minor such as diarrhea, abdominal pain, headache which resolve as treatment is discontinued
  • Superiority in the treatment of reflux esophagitis is supported by several reviews & trials
  • Initial management for patients w/ suspected extraesophageal reflux syndrome
    • Once- or twice-daily therapy for at least 12 wk as empiric therapy
    • Patients w/ partial response to once-daily therapy, adjust dose timing &/or consider twice-daily dosing, esp in patient w/ nighttime symptoms, sleep disturbance, or variable schedules
    • A specialist referral should be considered if patient fails empiric therapy w/ PPI as non-GERD etiologies must be excluded
  • Pregnant patients w/ GERD may be given a short-term PPI in the last two trimesters of pregnancy if clinically indicated
    • Other options include H2RAs, eg Ranitidine, & antacids except for preparations containing sodium bicarbonate
Adverse Reactions:
  • Generally well tolerated; most commonly reported: Headache, diarrhea, rash
  • Less common: GI effects (constipation, flatulence, abdominal pain, N/V, dry mouth); Dermatologic effects (pruritus, urticaria); Musculoskeletal effects (arthralgia, myalgia); Other effects (dizziness, fatigue, insomnia, cough, upper resp tract infection)
  • Hypersensitivity reactions, elevated liver enzymes, & isolated cases of photosensitivity & hepatotoxicity have been reported
Special Instructions:
  • Use w/ caution in patients w/ hepatic impairment; dose adjustment recommended
  • Concomitant use w/ Atazanavir or Nelfinavir is not recommended (PPIs reduce exposure to these drugs)
  • Exclude possibility of gastric malignancy prior to treatment
  • Bone fracture: several published observational studies suggest that PPI therapy may be associated with an increased risk for osteoporosis-related fractures of the hip, wrist or spine. Patients should use the lowest dose and shortest duration of PPI therapy appropriate to the condition being treated
Dosage Guidelines:
    a. Dexlansoprazole
  • Adult: 30 mg PO 24 hrly x 4 wk
    b. Esomeprazole
  • Adult & Childn ≥12 yr:
    • Initial therapy: 40 mg PO 24 hrly x 4-8 wk
    • Maintenance therapy: 20 mg PO 24 hrly
  • Similar adult doses may be given IV for those unable to tolerate oral medications
  • Childn 1-11 yr w/ ≥20 kg body wt:
    • 10-20 mg PO 24 hrly x 8 wk
  • Childn 1-11 yr w/ <20 kg body wt:
    • 10 mg PO 24 hrly x 8 wk
    c. Lansoprazole
  • Adult & Childn ≥12 yr:
    • Initial therapy: 30 mg PO 24 hrly x 4-8 wk or 30 mg IV (over 30 min) 24 hrly x 7 days
    • Maintenance therapy: 15 mg PO 24 hrly
  • Childn 1-11 yr w/ >30 kg body wt:
    • 30 mg PO 24 hrly x up to 12 wk
  • Childn 1-11 yr w/ <30 kg body wt:
    • 15 mg PO 24 hrly x up to 12 wk
    d. Omeprazole1
  • Adult:
    • Initial therapy: 20 mg PO 24 hrly x 4-12 wk or 40 mg IV (over 20-30 min) 24 hrly
    • Refractory cases: 40 mg PO 24 hrly for 8 wk
    • Maintenance therapy: 10-20 mg PO 24 hrly
  • Childn >1 yr w/ >20 kg body wt:
    • 20 mg PO 24 hrly x 2-4 wk
  • Childn >1 yr w/ 10-20 kg body wt:
    • 10 mg PO 24 hrly x 2-4 wk
    e. Pantoprazole2
  • Adult:
    • Initial therapy: 20-40 mg PO 24 hrly for 4-8 wk or 40 mg IV (over 2-15 min) 24 hrly x 7-10 days
    • Severe cases: 40 mg PO 24 hrly for 4-8 wk
    • Maintenance therapy: 20-40 mg 24 hrly
  • Childn >5 yr:
    • >40 kg body wt: 40 mg 24 hrly for up to 8 wk
    • 15-40 kg body wt: 20 mg 24 hrly for up to 8 wk
    f. Rabeprazole (Na rabeprazole, Sodium rabeprazole)
  • Initial therapy: 10-20 mg PO 24 hrly x 4-8 wk
  • Maintenance therapy: 10-20 mg PO 24 hrly

1Combination w/ sodium bicarbonate is available. Specific prescribing information may be found in the latest MIMS.
2Combination w/ Domperidone is available. Specific prescribing information may be found in the latest MIMS.


1.2. Histamine2-Receptor Antagonists (H2RAs)
  • Eg Cimetidine, Famotidine, Nizatidine, Ranitidine, Roxatidine
  • Recommended in divided doses for symptomatic relief of milder forms of GERD
  • Have a role in inhibiting nocturnal acid secretion in mild erosive esophagitis or NERD
    • When given either after an evening meal or at bedtime, H2RAs often provide effective nighttime relief
    • When given as a supplement to PPI therapy, only a small dose of H2RAs at bedtime is recommended & given at a well-separated time from PPI evening dose
  • Decrease gastric acid production, particularly in the postprandial state, w/o affecting esophagogastric barrier dysfunction
  • Associated w/ a low incidence of adverse effects (4%)
  • May be given intermittently to patients intolerant of PPIs
  • Numerous, randomized, controlled trials have shown that standard dose of H2RAs is more effective than placebo in the treatment of reflux symptoms & healing of esophagitis
Adverse Reactions:
  • CNS effects (headache, dizziness, somnolence, insomnia, agitation); GI effects (diarrhea, N/V); Other effects (rashes, myalgia, arthralgia)
  • Altered LFTs, reversible confusion in the elderly & those w/ renal failure have occasionally occurred
  • Rarely reported effects: Hepatotoxicity, hypersensitivity reactions, CV effects (tachycardia, bradycardia, hypotension), hematologic effects (leucopenia, thrombocytopenia, agranulocytosis), acute pancreatitis
  • Cimetidine has weak anti-androgenic effects; impotence & gynecomastia have occurred & are usually reversible
Special Instructions:
  • Intravenous injections should be given slowly; intravenous infusion is preferred (esp for high doses & in patients w/ CV impairment)
  • Use w/ caution in patients w/ hepatic & renal impairment; dose adjustment recommended
  • Cimetidine may reduce hepatic metabolism of some drugs through inhibition of cytochrome P450 isoenzymes; closely monitor those on oral anticoagulants, Lidocaine, Phenytoin or Theophylline; dose reduction may be necessary
Dosage Guidelines: 
    a. Cimetidine
  • 800 mg PO 24 hrly or 400-600 mg PO 12 hrly or 300-400 mg PO 6 hrly
  • Duration of treatment: 4-12 wk, depending on severity (All doses should be taken w/ food)
    b. Famotidine
  • Initial therapy: 20-40 mg PO 12 hrly x 6-12 wk
  • Maintenance therapy: 20 mg PO 12 hrly (May be taken w/ or w/o food)
    c. Nizatidine
  • 150-300 mg PO 12 hrly for up to 12 wk (May be taken w/ or w/o food)
    d. Ranitidine
  • 150 mg PO 12 hrly or 300 mg PO at bedtime for up to 8 wk or 50 mg IM or slow IV for 1-2 min 6-8 hrly or intermittent IV infusion at 25 mg/hr for 2 hr repeated 6-8 hrly
  • Severe cases: 150 mg PO 6 hrly x 12 wk
    e. Roxatidine
  • 75 mg PO 12 hrly or 150 mg PO at bedtime x 6-8 wk

2. Maintenance Therapy
  • Goal is to have a symptom-free patient w/o esophagitis
  • Use the lowest dose & least potent medication that can obtain a complete & sustained symptomatic response
  • The need for maintenance therapy is determined by the impact of the residual symptoms on the patient’s quality of life
  • Type of maintenance therapy based on duration of treatment:
    • Continuous maintenance therapy refers to daily administration of treatment for mths or even yrs to prevent relapse of GERD symptoms
      • Given mainly for those w/ moderate to severe erosive reflux disease
    • Discontinuous therapy is either intermittent or on-demand
      • Intermittent therapy is patient-initiated short courses of therapy w/ a fixed duration taken even after symptoms have resolved
      • On-demand therapy is when patient starts treatment when symptoms occur & continues until these are gone
      • Both intermittent & on-demand therapy are recommended for long-term maintenance of acid suppression & in patients w/ mild symptoms & w/ NERD

Options for Chronic Acid Suppression:
  • Step-up therapy involves starting treatment w/ the less potent agents & moving up for treatment response
    • If patient does not respond to an H2RA w/in 2 wk, switch to PPI
    • If patient does not respond to the standard once-daily treatment for 8 wk, double the dose of the same PPI (30 min prior to breakfast & 30 min prior to dinner) or switch to a different PPI
    • If patient still does not respond to above regimens, patient’s symptoms are likely not secondary to reflux & warrant diagnostic testing
  • Step-down therapy makes use initially of a potent acid suppressant, then decreasing dose or switching to less-potent agents
    • Begins w/ the patient taking PPI for 8 wk, followed by an H2RA if GERD symptoms were adequately controlled w/ a PPI
    • This is followed by stepping down further to on-demand use of antacids if patient was asymptomatic while taking an H2RA
    • Majority of patients who experienced symptom relief after being placed on more than a single daily dose of PPI can be successfully stepped down to single-dose therapy w/o recurrence of reflux symptoms
  • Maintenance treatment for GERD is recommended at the lowest effective dose
    • Step-down therapy should be attempted
  • Chronic PPI therapy for adequate symptom control
    • Even w/ adequate symptom control & PPI tolerability, the likelihood of long-term spontaneous remission of the disease is low
    • Though PPIs are generally safe w/ long-term use, careful consideration is required in patients at risk for complications, eg iron deficiency, vit B12 deficiency, increased susceptibility to enteric infections, fractures & pneumonia
  • For patients w/ suspected extraesophageal GERD syndrome w/ a concomitant esophageal GERD syndrome, maintenance therapy w/ once- or twice-daily PPIs

3. Adjunctive Pharmacotherapy
3.1. Antacids3 & Alginates
  • Effective in symptom relief; antacid-alginate combination is recommended for episodic & postprandial reflux symptoms
  • Usually taken after each meal & at bedtime
  • Alginate reacts w/ gastric acid creating a viscous gel or raft above the gastric contents that acts as a mechanical barrier to reduce reflux into the esophagus
    • Mode of action is physical & does not depend on systemic absorption
    a. Alexitol sodium
    Adverse Reactions:
  • Rarely N/V, constipation
    Special Instructions:
  • Use w/ caution in patients w/ renal insufficiency
    Dosage Guidelines:
  • 216 mg/tab
  • Adult & childn 6-12 yr: 1-2 tab PO 6-8 hrly (Doses should be taken on an empty stomach
    b. Aluminum hydroxide [Al(OH)3]
    Adverse Reactions:
  • Constipation; phosphate depletion may occur w/ prolonged use or in large doses
    Special Instructions:
  • Contraindicated in hypophosphatemia
  • Use w/ caution in chronic renal failure; may cause phosphate depletion
  • To reduce constipating effects, aluminum hydroxide is often given w/ magnesium-containing antacid (eg magnesium hydroxide, magnesium oxide)
    Dosage Guidelines:
  • 600 mg/tab
  • 1-2 tab PO 6 hrly (May be taken w/ or w/o food)
    c. Calcium carbonate (CaCO3)
    Adverse Reactions:
  • GI effects (constipation, flatulence); Metabolic effects (hypercalcemia, metabolic alkalosis)
    Special Instructions:
  • Contraindicated in hypercalcemia, presence of or history of renal calculi, hypophosphatemia, patients w/ suspected digoxin toxicity
  • Use w/ caution in renal impairment, hypercalcemia-associated diseases, hypoparathyroid disease
    Dosage Guidelines:
  • 500 mg/tab
  • 2-4 tab PO as symptoms occur
  • Max: 15 tabs (May be taken w/ or w/o food)
    d. Hydrotalcite
    Adverse Reactions:
  • Occasionally diarrhea, soft stools, dry mouth
    Special Instructions:
  • May interfere w/ absorption of tetracyclines
  • Use w/ caution in renal or cardiac disorder, diarrhea, hypermagnesemia
    Dosage Guidelines: 
  • 500 mg/tab; 100 mg/mL susp
  • Adult: 1000 mg PO
  • 6-8 hrly (Should be taken on an empty stomach)
    e. Magnesium hydroxide [Mg(OH)2]
    Adverse Reactions:
  • GI effects (diarrhea, abdominal cramps); hypermagnesemia in patients w/ renal impairment
    Special Instructions:
  • Contraindicated in intestinal obstruction, fecal impaction, renal failure
  • Use w/ caution in colostomy, ileostomy, electrolyte imbalance
  • Monitor for toxicity in patients w/ impaired renal function
  • Usually given in combination w/ an aluminum-containing antacid to decrease diarrhea
    Dosage Guidelines:
  • 400 mg/5 mL susp
  • 15 mL PO at bedtime (May be taken w/ or w/o food)
    f. Magnesium oxide
    Adverse Reactions:
  • GI effects (cramping, diarrhea, vomiting, upset stomach, paralytic ileus); Other effects (rashes, hives, itching, hypermagnesemia)
    Special Instructions:
  • Contraindicated in renal failure
  • Use w/ caution in renal impairment, bowel obstruction
  • Usually given in combination w/ an aluminum-containing antacid to decrease diarrhea
    Dosage Guidelines:
  • 84.5 mg/cap
  • 400 mg/day PO (Should be taken on an empty stomach)
    g. Sodium bicarbonate (NaHCO3)
    Adverse Reactions:
  • GI effects (cramps, belching, flatulence)
  • Excessive use of bicarbonate may lead to hypokalemia & metabolic alkalosis, esp in patients w/ impaired renal function
    Special Instructions:
  • Contraindicated in renal failure
  • Use w/ caution in renal impairment, bowel obstruction
  • Usually given in combination w/ an aluminum-containing antacid to decrease diarrhea
    Dosage Guidelines:
  • 325 mg/tab 
  • Adult: 3-6 tab PO 6 hrly (Should be taken w/ food)
  • 650 mg/tab
  • Adult: 2-4 tab PO 8 hrly (Should be taken w/ food)
3.1.1. Intestinal Adsorbent

a. Bismuth salicylate (Bismuth subsalicylate)

    Adverse Reactions:
  • Darkening of stool & tongue, hypersensitivity reactions
    Special Instructions:
  • Use w/ caution in patients w/ renal impairment
  • Avoid in patients w/ salicylate or aspirin sensitivity, history of severe Gi bleeding & coagulopathy
    Dosage Guidelines:
  • 262 mg/15 mL susp; 262 mg/tab; 524 mg tab
  • 524 mg PO every 1/2-1 hr 
  • Max dose: 8 doses/day

3Various combinations of antacids are available. Al & Mg are usually combined to decrease constipation/diarrhea. Please see the latest MIMS for available formulations.


3.2. Propulsives/Prokinetic Agents
  • Eg Domperidone, Metoclopramide, Itopride, Mosapride
  • Effective in patients w/ mild symptoms
  • Domperidone has the advantage of having less pyramidal effects
  • Oral Metoclopramide may be given to patients unresponsive to conventional therapy
  • Long-term use is not recommended because of risk of neurological & other adverse effects
    • Treatment duration should be kept as short as possible, ie up to 5 days (not to exceed 12 wk)
    a. Alizapride
    Adverse Reactions:
  • CNS effects (drowsiness, dizziness, headache, extrapyramidal symptoms or EPS); Endocrine effects (amenorrhea, galactorrhea); GI effect (diarrhea)
    Special Instructions:
  • Contraindicated in Parkinson’s disease, GI perforation, pheochromocytoma
  • Use w/ caution in renal impairment
  • May impair ability to drive or operate machineries
    Dosage Guidelines:
  • Adult: 75-300 mg/day PO in divided doses
  • Childn: 5 mg/kg/day
    b. Bromopride
    Adverse Reactions:
  • CNS effects (drowsiness, dizziness, headache, EPS, depression); Endocrine effect (galactorrhea); CV effects (hypotension, hypertension); GI effect (diarrhea)
    Special Instructions:
  • Contraindicated in GI hemorrhage, obstruction & perforation, in pheochromocytoma
  • Use w/ caution in renal impairment, children, Parkinson’s disease, history of depression
  • May impair ability to drive or operate machineries
    Dosage Guidelines:
  • Adult: 20-60 mg/day PO in divided doses
    c. Clebopride
    Adverse Reactions:
  • On large doses: Drowsiness, dizziness, breast tension
    Special Instructions:
  • Contraindicated in GI hemorrhage, obstruction & perforation, in tardive dyskinesia
  • Use w/ caution in children
  • May impair ability to drive or operate machineries
    Dosage Guidelines:
  • Adult: 0.5 mg PO 8 hrly (30 min before meals)
    d. Cisapride
    Adverse Reactions:
  • CNS effects (dizziness, depression); CV effect (chest pain); GI effects (nausea, abdominal cramps, borborygmi, diarrhea); Other effects (fatigue, lower back pain, rash, pruritus, angioedema, bronchospasm)
    Special Instructions:
  • Contraindicated in GI hemorrhage, obstruction & perforation
  • Use w/ caution in arrhythmias, ventricular tachycardia, ventricular fibrillation, history of heart disease, CHF, renal impairment, hypocalcemia, hypomagnesemia, respiratory disorders
    Dosage Guidelines:
  • Adult:
    • Initial therapy: 5 mg PO 6-8 hrly
    • Max dose: 40 mg/day
  • Childn:
    • Initial therapy: 0.2-0.8 mg/kg PO 6-8 hrly
    • Max dose: 20 mg/day
    • Doses to be taken 15 min before meals
    e. Domperidone4
    Adverse Reactions:
  • GI effect (abdominal cramps); Endocrine effects (elevated prolactin levels, galactorrhea, gynecomastia); Dermatologic effects (rash, urticaria)
    Special Instructions:
  • Contraindicated in GI perforation, hemorrhage & obstruction, in prolactinoma
  • Use w/ caution in renal & hepatic impairment, infants <1 yr
    Dosage Guidelines:
  • Adult:10-20 mg PO 6-8 hrly
  • Childn: 0.25-0.5 mg/kg body wt PO 6-8 hrly
  • Doses to be taken 15-30 min before meals & at bedtime
    f. Itopride  
    Adverse Reactions:
  • CNS effects (dizziness, headache, tremor); Endocrine effects (gynecomastia, increased prolactin levels); GI effects (diarrhea, constipation, abdominal pain, nausea, jaundice); Dermatologic effects (rash, redness, itching); Hematologic effects (leukopenia, thrombocytopenia)
    Special Instructions:
  • Contraindicated in GI perforation, hemorrhage & obstruction
  • Safety in children <16 yr has not been established
  • Itopride enhances the action of acetylcholine & may produce cholinergic side effects; data on long-term use are not available
    Dosage Guidelines:
  • Adult: 50 mg PO 8 hrly before meals
    g. Metoclopramide
    Adverse Reactions:
  • CNS effects (restlessness, drowsiness, headache, extrapyramidal reactions & dystonic reactions have been reported eg tardive dyskinesia & parkinsonian symptoms); Endocrine effects (increased prolactin resulting in galactorrhea or gynecomastia); GI effect (diarrhea)
    Special Instructions:
  • Avoid in patients in whom stimulation of muscular contractions may adversely affect GI conditions (eg GI hemorrhage, obstruction, perforation)
  • Should be avoided in patients w/ pheochromocytoma, epilepsy, Parkinson’s disease, history of depression & in patients taking drugs that can also cause extrapyramidal symptoms
  • Use w/ caution in patients w/ renal or hepatic impairment
    Dosage Guidelines:
  • Adult: 5-10 mg PO 8 hrly
  • Max dose: 30 mg/day
  • Childn >6 yr: Max of 0.5 mg/kg/day in 2 divided doses
  • Childn <6 yr: Max of 0.1 mg/kg in a single dose
  • Doses should be taken at least 15 min before meals
    h. Mosapride 
    Adverse Reactions:
  • CNS effects (dizziness, headache, lightheadedness); GI effects (diarrhea, abdominal pain, dry mouth, jaundice, increased triglycerides, elevated liver enzymes, taste abnormality, N/V); CV effect (palpitations); Hematologic effects (leukopenia, eosinophilia)
    Special Instructions:
  • Contraindicated in GI perforation, hemorrhage & obstruction
  • Should not be taken >2 wk
  • May impair ability to drive or operate machineries
    Dosage Guidelines:
  • Adult: 5 mg PO 8 hrly
  • May take before or after meals

4Combination w/ Pantoprazole is available. Specific prescribing information may be found in the latest MIMS.


4. Other drugs used in the treatment of GERD5
a. Alginic acid/Al(OH)3/Mg carbonate
    Adverse Reactions:
  • GI effects (diarrhea or constipation, abdominal distention, hiccups)
    Special Instructions:
  • Use w/ caution in patients w/ Na-restricted diet
    Dosage Guidelines:
  • 1-2 tab PO 12 hrly [per tab: Alginic acid 200 mg/Al(OH)3 30 mg/Mg carbonate 40 mg]
  • Max dose: 3 g of Al(OH)3, 2 g of Mg carbonate in a 24-hr period for <2 wk
b.  Al(OH)3-Mg carbonate/Attapulgite (activated)
    Adverse Reactions:
  • Related to Aluminium: Phosphorus depletion during prolonged use or at high dosages
    Special Instructions:
  • Use w/ caution in patients bedridden or w/ megacolon (risk of scatoma)
  • Take into account the dose of aluminium in case of renal insufficiency & chronic dialysis (risk of encephalopathy)
  • Avoid in patients w/ severe renal insufficiency and digestive tract stenosis
    Dosage Guidelines:
  • 1 sachet daily into a half glass of water after meals [per sachet: Al(OH)3-Mg carbonate 0.5 g/Attapulgite (activated) 2.5 g]
c. Na alginate/K bicarbonate  
    Adverse Reactions:
  • Skin rashes have been reported
    Special Instructions:
  • Use w/ caution in patients on Na-restricted diet, in patients <12 yr
    Dosage Guidelines:
  • Adult, elderly & childn >12 yr: 500-1000 mg (Na alginate) PO
  • Doses taken w/ food (after meals & at bedtime)
d. Na alginate/Na bicarbonate/Ca carbonate
    Adverse Reactions:
  • GI effect (abdominal distension)
    Special Instructions:
  • Use w/ caution in patients w/ Na- and Ca-restricted diet, in heart failure & renal dysfunction
  • May be used during pregnancy & lactation
    Dosage Guidelines:
  • Adult & childn >12 yr: 500-1000 mg (Na alginate) PO
  • Childn 6-12 yr: 250-500 mg (Na alginate) PO
  • Doses taken w/ food (after meals & at bedtime) 
e. Sucralfate
    Adverse Reactions:
  • GI effects (constipation; less frequently GI disturbances & dry mouth); Other effects (dizziness, skin rashes)
    Special Instructions:
  • Contraindicated in patients on dialysis
  • Use w/ caution in patients w/ renal impairment
  • Concomitant use w/ antacids should not be <30 min before or after Sucralfate
    Dosage Guidelines:
  • Adult: 1 g PO 6 hrly or 2 g PO 12 hrly
  • Should be taken on an empty stomach (1 hr before or 2 hr after meals)

5Various combinations are available. Please see the latest MIMS for available formulations.

Top

Antireflux Surgery


Indications for Antireflux Surgery
  • Failed medical management
    • Medication side effects, inadequate symptom control, refractory GERD (persistence of GERD symptoms in compliant patients despite standard treatment or twice-daily dosing of PPI for at least 8 wk)
  • Severe GERD complications (eg peptic stricture, Barrett’s esophagus)
  • Large hiatal hernia
  • Extraesophageal conditions (eg cough, asthma, chest pain, aspiration)
  • Young patients requiring long-term management
  • Patient preference
    • Despite success w/ medications, patient may opt for surgery due to cost of medications, life-long need to take acid-suppressive agents
    • However, patient should be advised against surgery if symptoms are well controlled on medical therapy

Antireflux Surgery
  • Has evolved from open type to a laparoscopic procedure & in recent years, to transoral incisionless fundoplication
  • Surgical success is highest in patients presenting w/ typical GERD symptoms & demonstrating good response to treatment w/ PPI
  • Esophageal manometry & ambulatory reflux studies should be done before surgery to rule out other disorders, eg achalasia, non-reflux-induced esophageal spasm, scleroderma

Fundoplication
  • Involves either a partial or a complete (360 degrees) wrap of the LES w/ a section of the stomach, thus, increasing LES pressure
  • Advantages include less pain, fewer incisional hernias, shorter hospital stay, quicker return to work, less defective wraps at follow-up endoscopy
  • Complications include inability to belch & vomit, persistent dysphagia, postprandial pain, epigastric fullness, bloating, temporary swallowing discomfort, intense flatus
  • Trans-oral or endoluminal fundoplication is a new modified version of an open or laparoscopic fundoplication & involves accessing the stomach through the mouth, eliminating the need for incisions
    • Is currently not recommended as an alternative to medical or traditional surgery as data are lacking to support its role
  • Recent publications have, however, noted long-term follow-up of patients who had antireflux surgery (up to 13 yr post-op) showed a high rate of symptom relapse which required continuing intake of antireflux medications
  • Expertise or experience of the surgeon performing the procedure is highly predictive of clinical success

Endoluminal Treatments
  • Recent procedures, eg titanium beads implantation & full-thickness plication, intend to reduce acid reflux episodes or transient lower esophageal sphincter relaxations & increase LES basal pressure
  • Currently performed in clinical trials as durable long-term benefits have not been shown

All dosage recommendations are for non-pregnant & non-breastfeeding women, non-elderly adults w/ normal renal & hepatic function unless otherwise stated.

 

Not all products are available or approved for above use in all countries. 

 

Products listed above may not be mentioned in the disease management chart but have been placed here based on indications listed in regional manufacturers’ product information.

 

Click the link below for specific prescribing information of products available in respective countries.

Brands available in:   Hong Kong   Indonesia   Malaysia   Philippines   Singapore   Thailand   Vietnam

Featured brands : Nexium in Singapore     Controloc in Malaysia

Top