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Acid Suppression For Chronic Heartburn
Dr. Minocha is a practicing gastroenterologist and author ofand is the author of How to Stop Heartburn; Simple Ways to Heal Heartburn and Acid Reflux.
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HISTAMINE-2 RECEPTOR BLOCKERS:
H2 receptor blockers (Zantac, Pepcid, Axid, Tagamet) work in about 50% of patients with GERD.
Rest require stronger acid blockade, i.e. proton pump inhibitors (PPIs). Five of them are available:
Prilosec represents the first generation and other PPIs have been shown to be superior to Prilosec in several studies.
ARE ALL PPIs SAME?
All PPIs are not created equal and are not pharmacologically similar. They differ with respect to their bioavailability, pharmacodynamics, drug interactions as well as specificity of action at the level of proton pump. The clinical significance of these differences remains to be established.
EFFECT OF MEAL:
Majority of patients require once a day PPI in morning about 30 minutes before breakfast. Ingestion before breakfast is especially important for products like Nexium whose bioavailability is affected significantly if taken with meal.
TIME OF INGESTION OF PPI
Studies have compared acid suppression comparing a single dose of PPI taken in morning versus the evening and have found the degree of acid suppression is better if taken in morning. However, a minority of patients who only have night-time reflux may benefit from single a evening dose only.
TWICE A DAY DOSING:
Estimates suggest that 25-45% patients may require twice a day dosing. In such cases, the second dose should be 30 minutes before supper and NOT at bedtime. In many cases, there is acid reflx and heartburn in middle of night despite PPI (nocturnal acid breakthrough) especially after a big meal. An addition of H2 receptor blocker at bedtime may help in such cases.
MULTIPLE DOSES OF PPI PER DAY:
A very small fraction of GERD patients may even require PPI 3-4 times a day. Before embarking on this, 24 hour pH profile should be checked on twice a day PPI to examine esophageal reflux.
PPIs AND CANCER:
Despite initial concerns about cancer risk from long term use of PPIs, this has not been borne out by long-term experience.
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