Gastroesophageal reflux disease (GERD) is the most common GI condition encountered in the outpatient setting; it affects about 20% of people in the US.

View the Comparison Table: H2-Receptor Antagonists and PPIs

Nonopioid drugs can be used in the treatment of many nociceptive and neuropathic pain conditions. Use of opioids for pain will be reviewed in a future issue.

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Gastroesophageal reflux disease (GERD) is the most frequent GI condition encountered in the outpatient setting; it affects about 20% of the US population. Heartburn and regurgitation are the classic symptoms of GERD.

View the Comparison Table: Drugs for GERD and Peptic Ulcer Disease

H2-RECEPTOR ANTAGONISTS (H2RAs) — Currently available H2RAs are listed in Table 1. These drugs inhibit the action of histamine at the H2-receptor of the gastric parietal cell, decreasing basal acid secretion and, to a lesser degree, food-stimulated acid secretion. All H2RAs are about equally effective for treatment of PUD and GERD. H2RAs are faster acting than PPIs in relieving symptoms of dyspepsia or GERD, but they are not as effective as PPIs in relieving symptoms or in healing erosive esophagitis. Repeated administration of H2RAs leads to pharmacologic tolerance and has been associated with the development of new dyspeptic symptoms. Rebound acid hypersecretion can occur after stopping H2RAs.

The FDA has approved Duexis (Horizon), a fixed-dose combination of the nonsteroidal anti-inflammatory drug (NSAID) ibuprofen and the H2-receptor antagonist (H2RA) famotidine, for symptomatic relief of osteoarthritis and rheumatoid arthritis and to decrease the risk of developing gastric and duodenal ulcers in patients at risk for NSAID-associated ulcers. Vimovo, a combination of the NSAID naproxen and the proton pump inhibitor (PPI) esomeprazole, is also approved by the FDA for prevention of NSAID-associated gastric ulcers.

Peptic ulcer disease (PUD) is usually caused by nonsteroidal anti-inflammatory drugs (NSAIDs) or by infection with Helicobacter pylori. Gastroesophageal reflux disease (GERD) can be caused by transient lower esophageal sphincter relaxation, reduced lower esophageal sphincter tone, hiatal hernia, delayed gastric emptying or hormonal changes due to pregnancy. Acid suppressive therapy is the cornerstone of management for both PUD and GERD.

Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) are common causes of peptic ulcer disease. Patients infected with Helicobacter pylori who take aspirin or another NSAID have an especially high risk. Drugs that have been tried for prevention of ulcers in patients taking NSAIDs including H₂-receptor antagonists, proton pump inhibitors (PPIs), aluminum- or magnesium-containing antacids, the prostaglandin misoprostol (Cytotec, and others), and antibiotics to eradicate H. pylori.

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Current guidelines recommend use of a proton pump inhibitor (PPI) to decrease the risk of gastrointestinal bleeding in patients taking clopidogrel (Plavix) with aspirin. A recent issue of The Medical Letter considered whether omeprazole (Prilosec, and others) or other PPIs could interfere with the antiplatelet effect of clopidogrel. The conclusion was that patients taking both drugs should probably continue to do so until more data became available. Several new publications require reconsideration of that recommendation.

Peptic ulcers caused by treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) are mainly gastric ulcers. Most duodenal and other gastric ulcers are caused by the gram-negative bacillus Helicobacter pylori. Gastroesophageal reflux disease (GERD) is caused by gastric acid reflux into the esophagus. Drugs that suppress gastric acid production are the primary treatment for GERD and peptic ulcers.

A recent advertisement for the proton pump inhibitor (PPI) lansoprazole (Prevacid - TAP) suggests that children who cough at night, complain of abdominal pain, refuse to eat, or have a bad taste in their mouths may all have gastroesophageal reflux disease (GERD). A Bunny's Tummy Trouble, a children's book about GERD published by TAP, is now available as a patient handout in pediatricians' waiting rooms. The use of acid-suppressive drugs in infants and children has increased markedly in recent years and many of these drugs are now available in child-friendly formulations. A table in the article lists some of the drugs used to treat GERD in children.

Most peptic ulcers not caused by nonsteroidal anti-inflammatory drugs (NSAIDs) are associated with infection of the gastric mucosa by the gram-negative bacilli Helicobacter pylori. The majority of NSAID-related ulcers are gastric. H. pylori infection causes both duodenal and gastric ulcers. Eradication of H. pylori promotes healing and markedly decreases recurrence of both duodenal and gastric ulcers (A Shiotamni and DY Graham, Med Clin North Am 2002; 86:1447; FKL Chan and WK Leung, Lancet 2002; 360:933). The first step in the management of peptic ulcers is the diagnosis and treatment of H. pylori.

The FDA recently approved the proton pump inhibitor omeprazole magnesium (Prilosec OTC) for over-the-counter use for treatment of frequent heartburn. It will be marketed in late September or early October. Five proton pump inhibitors, including omeprazole, are available by prescription in the US (Medical Letter 2001; 43:36).

Many different drugs are now used to treat rheumatoid arthritis. Nonsteroidal anti-inflammatory drugs (NSAIDs) have analgesic and anti-inflammatory effects, but may not affect the disease process. The "disease-modifying anti-rheumatic"drugs (DMARDs) have no immediate analgesic effects, but can control symptoms and may delay progression of the disease.

Most peptic ulcers not caused by nonsteroidal anti-inflammatory drugs (NSAIDs) are now thought to be associated with infection of the gastric mucosa by the gram-negative bacilli Helicobacter pylori. The majority of NSAID-related ulcers are gastric. H. pylori have been associated with both duodenal and gastric ulcers. Eradication of H. pylori promotes healing and markedly decreases recurrence of both duodenal and gastric ulcers (AH Soll, JAMA, 275:622, 1996).

Most peptic ulcers not caused by nonsteroidal anti-inflammatory drugs (NSAIDs) are now thought to be associated with infection of the gastric mucosa by the gram-negative bacilli Helicobacter pylori (NIH Consensus Development Panel, JAMA, 272:65, July 6, 1994). NSAID-related ulcers are usually gastric. H. pylori have been associated with both duodenal and gastric ulcers.

Drugs that accelerate healing and prevent relapse or reurrence of peptic ulcers act either by decreasing gastric acidity or by enhancing mucosal defense mechanisms. Risk factors that may cause breakdown of mucosal defenses include the use of aspirinor other nonsteroidal anti-inflammatory drugs (NSAIDs) and the presence of Helicobacter pylori bacterial in the gastric antrum (AH Soll, Engl J Med, 322:909, 1990; WL Peterson, N Engl J Med, 324:1043, 1991).

Nizatidine (Axid - Lilly), a new H2-receptor antagonist similar to cimetidine (Tagamet), ranitidine (Zantac) and famotidine (Pepcid), was recently approved by the US Food and Drug Administration for treatment of active duodenal ulcer and for maintenance therapy after healing. Cimetidine, ranitidine and famotidine are also approved for treatment of pathological hypersecretory conditions such as Zollinger- Ellison syndrome; cimetidine is approved in addition for treatment of gastric ulcers.