Medication Summary
A therapeutic response to treatment for gastroesophageal reflux may take up to 2 weeks. If treatment is successful, weight increases and vomiting episodes decrease. Recurrent aspiration pneumonia or apnea is cause for decreased length of medical therapy. Note that the so-called prokinetic agents have been omitted from the following drug list. No currently available prokinetic drug (eg, metoclopramide) has been demonstrated to exert a significant influence on the number or frequency of reflux episodes.
Antacids
Class Summary
These agents are used as diagnostic tools to provide symptomatic relief in infants. Associated benefits include symptomatic alleviation of constipation (aluminium antacids) or loose stools (magnesium antacids).
Aluminum hydroxide (ALternaGEL)
Aluminum hydroxide increases gastric pH (>4) and inhibits the proteolytic activity of pepsin, reducing acid indigestion. Antacids can initially be used in mild cases. Aluminum hydroxide has no effect on the frequency of reflux but decreases its acidity.
Magnesium hydroxide (Phillips Milk of Magnesia)
Magnesium hydroxide is used as an antacid to relieve indigestion. It also causes the osmotic retention of fluid, which distends the colon and increases peristaltic activity, providing a laxative effect. This agent forms magnesium chloride in vivo after reacting with stomach hydrochloric acid.
Histamine H2 Antagonists
Class Summary
Like antacids, these agents do not reduce the frequency of reflux but do decrease the amount of acid in the refluxate by inhibiting acid production. All H2 -receptor antagonists are equipotent when used in equivalent doses. They are most effective in patients with nonerosive esophagitis. H2 -receptor antagonists are considered the drugs of choice for children because pediatric doses are well established and the medications are available in liquid form.
Nizatidine (Axid)
Nizatidine competitively inhibits histamine at the H2 receptor of the gastric parietal cells, resulting in reductions in gastric acid secretion, gastric volume, and hydrogen concentrations.
Cimetidine (Tagamet)
Cimetidine inhibits histamine at the H2 receptors of gastric parietal cells, causing reductions in gastric acid secretion, gastric volume, and hydrogen ion concentrations.
Ranitidine (Zantac)
Ranitidine inhibits histamine stimulation of the H2 receptor in gastric parietal cells, reducing gastric acid secretion, gastric volume, and hydrogen ion concentrations.
Famotidine (Pepcid)
Famotidine competitively inhibits histamine at the H2 receptors of gastric parietal cells, reducing gastric acid secretion, gastric volume, and hydrogen ion concentrations.
Proton Pump Inhibitors
Class Summary
These agents are indicated in patients who require complete acid suppression (eg, infants with chronic respiratory disease or neurologic disabilities). Administer proton pump inhibitors with the first meal of the day. Children with nasogastric or gastrostomy tubes may have granules mixed with an acidic juice or a suspension; tubes must then be flushed to prevent blockage.
Lansoprazole (Prevacid)
Lansoprazole suppresses gastric acid secretion by specific inhibition of the H+/K+-adenosine triphosphatase (ATPase) enzyme system (ie, proton pump) at the secretory surface of the gastric parietal cell. The drug blocks the final step of acid production, inhibiting basal and stimulated gastric acid secretion and therefore increasing gastric pH. Lansoprazole's effect is dose related. The drug is easy to administer to children because it is available as a capsule or an oral disintegrating tablet or in granular form for use in an oral suspension.
Omeprazole (Prilosec)
Omeprazole decreases gastric acid secretion by inhibiting the parietal cell H+/K+-ATPase pump. It is used for the short- and long-term treatment (4-8wk to 12mo) of GERD.
Esomeprazole (Nexium)
Esomeprazole is an (S)-isomer of omeprazole. It inhibits gastric acid secretion by inhibiting the H+/K+-ATPase enzyme system at the secretory surface of the gastric parietal cells. Esomeprazole is used in severe cases and in patients not responding to H2-antagonist therapy. The drug is administered for up to 4 weeks to treat and relieve the symptoms of active duodenal ulcers; it may be used for up to 8 weeks to treat all grades of erosive esophagitis.
Dexlansoprazole (Dexilant)
Dexlansoprazole suppresses gastric acid secretion by specifically inhibiting the H+/K+-ATPase enzyme system at the secretory surface of gastric parietal cells.
Rabeprazole sodium (AcipHex)
Rabeprazole sodium suppresses gastric acid secretion by specifically inhibiting the H+/K+-ATPase enzyme system at the secretory surface of gastric parietal cells.
Pantoprazole (Protonix)
Pantoprazole suppresses gastric acid secretion by specifically inhibiting the H+/K+-ATPase enzyme system at the secretory surface of gastric parietal cells.
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The image is a representation of concomitant intraesophageal pH and esophageal electrical impedance measurements. The vertical solid arrow indicates commencement of a nonacid gastroesophageal reflux episode (diagonal arrow). The vertical dashed arrow indicates the onset of a normal swallow.
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Algorithm for evaluation and "step-up" management of gastroesophageal reflux (GER).
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Illustration of the Nissen fundoplication. Note how the stomach is wrapped around the esophagus (360-degree wrap).
