Gastro-oesophageal reflux disease (GORD) is a condition in which stomach acid refluxes into the oesophagus causing cellular damage. Its incidence has increased over the past few decades, presumably due to an increased rate of obesity (1). Other risk-factors for GORD include increasing age, being Caucasian, smoking and being male (2).
The stomach is normally separated from the oesophagus by a muscular sphincter, which remains closed. In GORD, the sphincter is defective and the acidic contents of the stomach can interact with the oesophagus. This causes a variety of symptoms including regurgitation and heartburn. Regurgitation refers to the appearance of stomach contents in the mouth or throat without nausea.
More severe symptoms, requiring medical attention include (2):
Over-the-counter approaches to GORD symptoms include antacids or hydrogen-receptor blockers. These drugs help reduce acid production by the stomach. These drugs work best when combined with life-style modifications, such as weight loss and avoiding taking a meal three hours before sleeping. A reduction in BMI by 3.5 units, can lead to a decrease in GORD symptoms by up to 40%.
If these approaches are un-successful, doctors may propose a trial period of 4-8 weeks with proton pump inhibitors (PPIs). PPIs reduce acid production by the stomach and may relieve symptoms rapidly. PPI therapy is most effective if the drugs are taken 30-60 minutes before a meal (typically breakfast) (2).
PPIs are more potent than over-the-counter medication. However, if treatment with PPIs is un-successful at reducing symptoms, the diagnosis of GORD is less likely, but not excluded (3).
If PPI therapy fails to relieve symptoms, then an endoscopy may be performed. Unfortunately, a normal endoscopy can appear in patients with GORD and so a negative result does not exclude GORD. However, an endoscopy can be used to exclude Barrett’s oesophagus (2).
If PPI therapy is successful, then patients may be advised to reduce their dose of PPIs to a “when-required” approach. They should continue implementing life-style modifications and use the less potent over-the-counter medications in preference to PPIs, if plausible. Alternatively, the doctor may experiment with the dose until the minimum dose that effectively controls symptoms is achieved (2).
Side-effects of PPIs include headaches and diarrhoea and this is probably associated with the poor drug-adherence rate (approx. 50%).