This Page Intentionally Left Blank - Int Medical

Gastroesophageal reflux disease
KALANI OLMSTED AND DEBORAH B. DIERCKS
n Agents
n Morphine
n Antacids
n Proton pump inhibitors
n H2-Receptor antagonists
n Sucralfate
n Prokinetic drugs
n Evidence
The etiology of chest pain is often unclear upon initial patient evaluation.
Given this lack of clarity, and the fact that acute coronary syndromes claim a
prominent position in the differential diagnosis, opioids such as morphine
are often used early in patients subsequently diagnosed with gastroesophageal
reflux disease (GERD). In fact, morphine effectively relieves GERD pain
by decreasing the rate of transient lower esophageal sphincter relaxations
and by increasing tone – and thus decreasing volume – in the proximal
stomach. 1,2
Antacids (e.g. aluminum hydroxide, magnesium hydroxide, calcium carbonate)
provide GERD relief by buffering the refluxed gastric contents. 3,4
Antacids are readily available, relatively safe, and fast acting. Although they
tend to be insufficient as monotherapy, antacids represent a viable option for
occasional symptom relief, especially when employed in an adjunctive role. 3,5
Antacids constitute first-line GERD therapy in pregnancy. 6 Most antacids
are safe in pregnancy, but agents in this class can interfere with iron absorption
and so must be taken at times distant from ingestion of prenatal vitamins
and iron supplements. 7
Proton pump inhibitors (PPIs) are a first-line treatment for noncardiac
chest pain, and for GERD in particular 3,5,8–10 All PPIs effectively inhibit gastric
225