Proton pump inhibitor as first-line drug for persistent GORD without alarm features in adults
In adults, the first-line drug for persistent reflux (stomach acid washing up into the oesophagus) without alarm features (red flags) is a proton pump inhibitor, which blocks the acid pump.
Remember
When reflux symptoms keep returning in adults and there are no alarm features, give a standard-dose proton pump inhibitor for 4 to 8 weeks. Antacids and alginates are for short-term relief only.
Memory aid
an H2-receptor antagonist turns off one tap feeding the pump, whereas a PPI blocks the pump itself
Picture the proton pump as fed by three taps: an H2-receptor antagonist closes only one of them, while a proton pump inhibitor blocks the pump itself.
Gastro-oesophageal reflux disease, or GORD, means stomach acid repeatedly washing back up into the oesophagus (the gullet). It causes heartburn (burning behind the breastbone) and a sour taste. Lifestyle measures come first: weight loss, stopping smoking, smaller meals and avoiding late-evening meals. Antacids (which neutralise acid that is already in the stomach) and alginates (which form a gel raft over the stomach contents) are used for occasional, symptom-driven relief.
When symptoms persist, the next step is a proton pump inhibitor (PPI), such as omeprazole or lansoprazole, at standard dose for 4 to 8 weeks. This is the first-line drug treatment when there are no alarm features, meaning red flags such as food sticking on swallowing, repeated vomiting or unintentional weight loss. Alarm features, or symptoms that do not respond to treatment, point towards endoscopy (a camera test of the oesophagus and stomach).
PPIs act at the final step of acid production. Parietal cells (the acid-secreting cells of the stomach lining) use an enzyme called the H+/K+ ATPase, the proton pump, to push acid into the stomach. Histamine, gastrin and acetylcholine, the three stimulants of acid secretion, all converge on this one pump, so PPIs are the most powerful acid suppressants. An H2 receptor antagonist such as famotidine blocks only the histamine route to the acid-secreting cell, so it is weaker, and it is an alternative if a PPI does not help.
If symptoms recur after the course, a PPI can be continued at the lowest dose that controls them. If symptoms persist on a PPI, the options include doubling the dose, switching PPI or referral for endoscopy, and an H2 receptor antagonist can be tried if a PPI does not help.
Key facts
- First course
- in adults, a standard-dose proton pump inhibitor for 4 to 8 weeks is the first-line drug treatment for persistent reflux without alarm features.
- Mechanism
- a PPI irreversibly blocks the H+/K+ ATPase, the proton pump, which is the final common pathway of acid secretion.
- Antacids and alginates
- they relieve symptoms in the short term and are for occasional, symptom-driven use, not for regular use over long periods.
- If symptoms persist on a PPI
- the options include doubling the dose, switching PPI or referral for endoscopy, and an H2 receptor antagonist can be tried if a PPI does not help.
- Helicobacter pylori
- this stomach bacterium is tested for with a stool antigen test or urea breath test, and eradication (a PPI plus two antibiotics) is given only if the test is positive.
- Alarm features
- difficulty swallowing, repeated vomiting, unexplained weight loss or bleeding point towards endoscopy.
Exam traps
- Starting a proton pump inhibitor at double the standard dose is wrong for a first course, because doubling the dose is a step for symptoms that persist despite a standard-dose PPI.
- Reflux symptoms alone do not show Helicobacter pylori infection, so triple therapy (a PPI plus two antibiotics) is not started without a test first.
- An H2 receptor antagonist is not the preferred first-line drug for persistent reflux, because it blocks only one of the three signals that drive acid secretion and is weaker than a proton pump inhibitor.
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