Surgical therapy is generally undertaken when medical therapy is ineffective or not desired by the patient. Surgery to improve the barrier between the stomach and esophagus is an appropriate option if the patient has a mechanically defective cardia as defined by low LES (lower esophageal sphincter) pressure (<6 mmHg), short LES length (<2 cm) or short intra-abdominal LES segment (<1 cm). Ag
e, comorbid disease states, and medication and lifestyle compliance must be considered when evaluating whether surgery is indicated over continued medical therapy.
|Table 7. The Pharmacist’s Role in the Treatment of GERD|
|• Provide patient information on GERD• Educate patient on lifestyle modifications and medical therapies
• Stress adherence to therapy to prevent relapse
• Prevent drug interactions
• Adjust dosage of concurrent medications when needed
• Determine whether OTC therapy is successful
• Refer patient to physician when symptoms are not relieved or if alarm symptoms (dysphagia, weight loss, anemia, GI bleeding) are present
Management of gastroesophageal reflux disease (GERD) depends mainly on the severity of symptoms and esophagitis and outcome of initial therapy. In patients with mild to moderate symptoms, lifestyle modifications and antacids or over-the-counter H2 receptor antagonists should be recommended. In patients with moderately severe symptoms with nonerosive disease, prokinetic drugs and H2 receptor antagonists at full prescription doses are usually efficacious. A proton pump inhibitor should be the mainstay of therapy in patients with moderate to severe esophagitis or complications associated with GERD. Combination therapy with a prokinetic agent may be helpful in patients with delayed gastric emptying. In a recent cost-effectiveness analysis, proton pump inhibitors were found to be more cost-effective than H2 receptor antagonists in patients with significant symptoms and in institutional settings.
The pharmacist’s role in the treatment of gastroesophageal reflux disease includes educating patients not only about the drugs used to treat the disease and their associated adverse effects, but also about the disease itself. Pharmacists must aid patients in making the decision as to when to seek help from their physician, because the pharmacist may be the first health professional patients contact. When a patient approaches the pharmacist with complaints of heartburn and is seeking medication, an initial assessment must be made. Alarm symptoms — such as gastrointestinal bleeding, dysphagia or weight loss or continuous use of over-the-counter medications for greater than two weeks — should prompt the pharmacist to refer the patient to a physician. If the patient is young (<45 years of age), with mild symptoms and no alarm symptoms, the pharmacist should provide counseling on dietary and lifestyle modifications as well as prevention strategies.
Assistance should be given to the patient in the selection of the most appropriate over-the-counter medication based on individual efficacy, potential for adverse effects and drug interactions and cost. Education should be provided to the patient regarding the recommended medications, including their associated adverse effects. Pharmacists should educate patients on the difference between mild symptoms and more severe ones that may require notification of their physician. Referral to the patient’s physician should be made if there is no improvement in symptoms after two weeks of therapy.
For patients who present with a prescription for a GERD medication, the pharmacist should evaluate dosing regimen, potential for adverse drug reactions and drug interactions. This evaluation, along with recommendations regarding therapy changes, should be discussed with the physician.