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Gastroesophageal reflux disease 227
this high-dose therapy is continued for two to four weeks. 5,19,20 However, for
on-demand relief of mild GERD pain, RCT data have indicated that panto-
prazole can be administered in a lower dose of 20 mg PO without loss of
efficacy, compared with the 40 mg oral dose. 21 Similarly, RCT data for
prevention of nighttime GERD symptoms, have demonstrated that 20 mg PO
esomeprazole is as effective as a 40 mg dose of the same medication (about
50% have resolution of symptoms). 22
Although pain relief can be seen in as little as two days in patients who are
likely to be helped by PPIs, a month should be allowed for a full response. 5
PPIs are a third-tier choice (after antacids, sucralfate, and ranitidine) for
GERD during pregnancy.
Meta-analysis finds PPIs are ineffective for GERD-associated laryngitis pain. 23
H2-receptor antagonists such as ranitidine (150 mg PO as needed for
GERD pain) have been shown in double-blinded trials to achieve better ondemand
pain relief than antacids. 24 Since H2-receptor antagonists block
only one gastric parietal cell acid secretion mechanism (i.e. the histaminic),
they are less useful than PPIs for GERD. 3,5,20,25 The H2-receptor antagonists
are, however, useful adjuncts for nocturnal pain relief in patients with
incomplete symptomatic response to PPIs. 3,26
H2-receptor antagonists, specifically ranitidine (pregnancy category B,
also safe in breastfeeding) constitute the second tier (after antacids and
sucralfate) in the treatment of GERD during pregnancy. 6,27
Sucralfate forms a protective barrier by binding to injured gastroesophageal
mucosa. Its negligible systemic absorption translates into particular
utility of as first-line therapy for mild-to-moderate GERD during pregnancy
(it is Pregnancy Category B). 3,6,7
Prokinetic drugs such as metoclopramide and cisapride are postulated to
relieve GERD by increasing resting lower esophageal sphincter tone and
increasing gastric emptying. Data from an RCT showed that cisapride
(20 mg PO twice daily) significantly reduced GERD pain. 28 Though most
acute care providers commonly use metoclopramide with minimal adverse
effect, there are reports of prokinetic drugs causing CNS (e.g. with metoclopramide)
or cardiac (e.g. with cisapride) toxicity. Furthermore, RCTs show
that the addition of metoclopramide to H2-receptor antagonists or PPIs