Pharma Update - Keeping Acid Reflux in Check

A New Arsenal of Pharmaceuticals Aims to End GERD

The human body has a variety of methods for keeping things at bay and in place. Eyelashes bat away dangerous germs. Nose hairs intend to prevent pathogens from being inhaled. The rib cage houses the internal organs. Several sphincters seal perfectly to keep acids where they belong.

However, each of these survival mechanisms can fail, causing a variety of medical problems. When the lower esophageal sphincter, which connects the esophagus to the stomach, weakens, stomach acid can escape upward into the esophagus. This is the cause of heartburn. The acid irritates the lining of the esophagus and during prolonged exposure, can cause serious tissue damage.

While heartburn is becoming more common in the US because of changing diets and a more sedentary lifestyle, the burning sensation more than twice a week could be the sign of a more serious problem--gastroesophageal reflux disease (GERD). Symptoms of GERD include: bitter stomach fluid coming into the mouth, hoarseness, repeatedly feeling the need to clear the throat, difficulty swallowing, wheezing or coughing, and a worsening of symptoms after eating.¹

While mild forms of GERD can be treated with lifestyle changes, more serious stages of the disease require pharmaceuticals and/or surgery. A physician who suspects a patient could have GERD may begin treatment by recommending several changes in day-to-day behaviors.

• The following acid-producing foods should be eliminated from the diet: chocolate, peppermint, coffee, alcoholic beverages (specifically red wine), spices, onion, citrus, carbonated beverages, tomato and tomato juice, pepper, and fried or fatty foods.
• If the patient is a smoker, nicotine greatly increases stomach acids. Avoid smoking.
• The patient should eat an early dinner and not lie down until three hours after eating. It is also important to avoid snacking before going to sleep.
• The head should be elevated during sleep.
• Obesity can add pressure to the upper abdomen. Obese patients with GERD symptoms should make an effort to lose weight.^1,2

For those patients who are in a more severe stage of GERD, these changes in behavior may not make a difference. From this point, the physician is left with several diagnostic options. A manometry probe designed with sensors for sphincter studies can measure the pressure of the muscles in the esophagus. Jeff Sawyer, a product manager at Sandhill Scientific in Highlands Ranch, CO, said the probe is inserted transnasaly. He said the procedure can take between 15 minutes and 1.5 hours and it is generally not discomforting for patients. A topical anesthetic can help endoscopy team members to insert the catheter, yet keep their patients coherent and awake.

Similarly, a pH monitoring system can let a physician insert a sensory catheter transnasaly to determine if a person is suffering from acidic reflux. Sawyer said a pH system ranks substances on a 1-7 scale. The patient's monitor determines how many times during a 24-hour period the sensor, located above the lower esophageal sphincter, comes into contact with an acidic substance, which ranks 4 or below on the scale.

When and if it is determined the patient has GERD, the need for action is immediate. When left untreated, GERD can cause strictures, Barrett's esophagus, and may lead to esophageal cancer.

While some patients may use antacids or H2-receptor blocker drugs, a new class of pharmaceuticals has been created specifically to target acid. The stomach has millions of cells working to create acid through pumps. These pumps assist the stomach with the digestive process. However, when there are too many acid pumps working at once in combination with a weak lower esophageal sphincter, acid reflux can occur.

Proton pump inhibitors are a relatively new technology in the pharmaceutical field. They target acid pumps and push these cells to stop acid secretion. In turn, the stomach still has enough acid to digest food, but isn't overrun by errant acid that flows back up into the esophagus.

One of the more well-known pills in this class of drugs is Nexium, the "purple pill" developed by AstraZeneca. The London-based pharmaceutical giant touts that Nexium (esomeprazole magnesium generically) works not only to stop GERD, but to also heal the damage caused by the acidic refluxes in the esophagus. The company's clinical tests have reportedly shown that 9 out of 10 people with acid reflux-related erosions were successfully treated with their pill.²

Jim Coyne, senior manager of gastrointestinal public affairs at AstraZeneca, said Nexium is indicated for healing of erosive esophagitis, maintenance healing of erosive esophagitis, treatment of heartburn, and other symptoms of GERD.

"Nexium blocks the final step of acid production by inhibiting an enzyme system at the secretory surface of the stomach's parietal cell. It does not affect the tone of the lower esophageal sphincter," he said.

If pharmaceuticals do not help a patient's GERD, there are also surgical options. A laparoscopic fundoplication can be performed to strengthen the lower esophageal sphincter.² The fundus, or the base of an organ, is wrapped during this procedure. The fundus of the stomach is wrapped around the esophagus and sutured to keep the organ in place. This keeps the chest separate from the abdomen, eliminating any potential hiatal hernias. The result of the procedure looks like a buttoned shirt with the collar of the fundus and the esophagus imbricated in the wrap.³

The procedure creates a new valve for the esophagus to empty in to the stomach but prevents acid from escaping back into the esophagus. This eliminates GERD. The entire procedure can be accomplished with five small incisions made in the chest.³

While GERD patients may be discomforted by their condition, they are fortunate to have such a variety of technologies available. Acid reflux is easily managed and controlled thanks to improved pharmaceuticals and medical innovations.

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