Gastroesophageal reflux disease (GERD) is a common gastrointestinal condition occurring due to the retrograde flow of refluxate from the stomach into the esophagus. The most typical symptoms in GERD are regurgitation and heartburn. Gastro-esophageal refluxate contains a variety of noxious agents, mainly acid but also pancreatic enzymes, pepsin and bile salts. Exposure of the esophageal mucosa to these agents may result in critical injuries to the delicate structures, resulting in reflux esophagitis, esophageal stricture, Barrett’s esophagus, esophageal adenocarcinoma and others.
Even though GERD is a very common clinical diagnosis, its pathogenesis is quite complicated. In many cases, this is due to inappropriate lower esophageal sphincter (LES) function. The pathogenesis of GERD involves an interplay of neurological, chemical, mechanical and psychological mechanisms, which contribute to symptom presentation and influence diagnosis and treatment. Owing to the multifactorial development, many patients may continue to experience detrimental symptoms due to GERD, despite prolonged acid suppression with proton pump inhibitor therapy.1
Pharmacotherapy for GERD
Treatment of GERD is broadly targeted at providing symptomatic relief and
preventing the onset of complications such as esophagitis or adenocarcinomas.
Treatments take a multifactorial approach that includes lifestyle
modifications, medical management with antacids, antisecretory agents, and
other pharmacotherapeutic options. Occasionally, surgery may be advised in
refractory cases.
The commonly prescribed pharmacotherapeutic agents include -
1) PPIs (Proton Pump Inhibitors)
Proton pump inhibitors (PPIs) are first choice treatment in GERD. Standard PPI
therapy is effective in 90%–100% of people with mild symptoms; however,
effectiveness decreases to 60% in people with the most severe disease.2Evidence
indicates that for maintenance therapy, low-dose PPI is as effective as high
dose.3 However, despite their efficacy, about 20–30% of patients
report an insufficient response and alternative drugs are required.4
2) Prokinetic drugs
Prokinetic drugs can be useful adjuncts in the treatment of GERD by increasing
the LES pressure, enhancing gastric emptying, or improving peristalsis.
Clinically, however, these drugs are marginally useful.
3) Mucosal protective drugs
Mucosal protective agents are inferior to antacid/ alginates, H2RAs and PPIs in
the treatment of erosive esophagitis and in relieving symptoms of GERD. They have
limited usefulness in the treatment of duodenal and gastric ulcers.
4) Histamine and H2 Receptor Antagonists
H2RAs are safe and effective in controlling symptoms of acute reflux disease.
It is important that patients visit their physician before using H2RA
medications beyond their 14-day indication.5
Guideline Recommendations for GERD Management
Although PPIs stay the first choice for treatment of GERD, often other drugs
are prescribed as an adjunct for different variants of GERD (based on duration
and symptoms), which can not be treated by PPIs alone. Different
guidelines suggest monotherapy or a combination of one or more of these
medications to treat GERD.6
Alginate-based formulations act primarily by a unique nonsystemic mechanism
of action, different from antacids, PPIs or histamine H2-receptor antagonists
(H2 antagonists). Upon coming into contact with gastric acid, alginate rapidly
forms a gel ‘raft’ of near-neutral pH that creates a protective barrier above
the acidic gastric contents. This alginate raft protects the oesophageal
mucosa by limiting gastric reflux into the oesophagus.7
Alginate-based formulations have been shown to act more rapidly than PPIs
and H2 antagonists,8 and to provide longer-lasting relief of
symptoms than conventional antacids. These formulations have been shown to
provide effective relief of upper gastrointestinal (GI) symptoms, either as a
monotherapy or in combination treatment. These findings suggest that
alginate-based formulations could be considered as an alternative or add-on
therapy in GERD patients, including those with non-erosive reflux disease or
NERD.9
Alginate Therapy is Clinically Established in GERD
Manabe et al. investigated the benefit of adding alginate to antacid therapy
in patients with NERD. The authors conducted a randomized, open-label, parallel
group multicenter study, including 76 patients, randomly assigned into two
groups, receiving either alginate and antacid, or antacid alone. They reported
that 56% of patients from the first group presented resolution of symptoms
compared to only 25.7% of the ones from the second group, and concluded that
combined PPI and alginate therapy was superior to PPI therapy alone.10
Several other studies have found therapeutic benefits of
alginates in GERD
• An immediate therapeutic action with alginate (within 1h of administration)
was observed, which was considered faster in comparison to a PPI or an
H2-receptor antagonist (H2RA).11
• Alginate was found superior to placebo and antacids for the treatment of mild
GERD, and this monotherapy seems to be beneficial as an initial treatment.12 In
the sodium alginate group, symptom resolution was observed to be higher, and
the speed of action was faster in comparison to the antacid group.
• Alginates were also shown to be effective for self-medication to control mild
reflux disease.13
• In the most recent randomized clinical trial, an alginate-containing product
has been shown to be superior to antacid in post-supper suppression of the acid
pocket in obese individuals.14
• Alginate-based therapies were found to be more effective in treating GERD
symptoms as compared with placebo or antacids.15
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