How to use medication for GERD when stomach acid worsens symptoms

Author: Wang Feng, Attending Physician at the Specialty Medical Center of the Rocket Force of the People's Liberation Army of China.

Review: Wu Jiming, Chief Physician at the Medical Center of the Rocket Force of the People's Liberation Army of China.

Many individuals mistakenly believe that gastroesophageal reflux disease (GERD) is caused by excessive gastric acid secretion, which represents a common cognitive bias. In fact, the primary cause of GERD is not an excess of stomach acid, but the relaxation of the lower esophageal sphincter, leading to its dysfunction.

The stomach is inherently an acidic environment; it is only under acidic conditions that gastric acid, pepsin, and other substances effectively digest food. A decrease in gastric acid concentration may actually impair digestive function. For healthy individuals, the cardia functions predominantly as a one-way valve, effectively preventing gastric acid from refluxing, hence symptoms do not manifest. Although excessive gastric acid can cause other gastric disorders, it is not the direct etiological factor for GERD.

The primary cause of gastroesophageal reflux is associated with the relaxation of the lower esophageal sphincter in about 80% to 90% of cases. In a minority of cases, insufficient gastric motility or delayed gastric emptying can cause an increase in gastric pressure, while poor esophageal motility can impede the clearance of normal physiological reflux, potentially triggering reflux. Therefore, the primary issue lies within the dysfunction of the lower esophageal sphincter rather than the gastric acid itself.

Figure 1: Original copyright image, not authorized for reproduction.

In gastroesophageal reflux, gastric acid acts more like a "scapegoat." Acid-suppressing medications commonly employed in clinical practice are essentially workaround measures that merely alleviate symptoms without addressing the underlying cause. By reducing gastric acid secretion, these medications decrease the volume of reflux, thus mitigating symptoms, but they do not repair the compromised lower esophageal sphincter. Moreover, long-term use of acid suppressants can negatively affect digestive function and present potential risks, such as gastric polyps and osteoporosis. Patients with GERD should be mindful of their diet, as overeating, high-fat foods, sugary items, spicy dishes, alcohol, coffee, and strong tea can all worsen reflux symptoms.

Figure 2: Original copyright image, unauthorized for reproduction.

Medications for the clinical treatment of GERD are primarily classified into three categories, which should be utilized in combination according to the patient's specific conditions.

The first category includes acid-suppressing drugs, which are currently the most commonly used primary medications and can be categorized into two types. The first type consists of potassium ion inhibitors, commonly referred to as "lasers"; the second type includes proton pump inhibitors, known as "prazole" preparations. These medications effectively inhibit gastric acid secretion, reduce the volume of reflux, alleviate symptoms, and manage reflux esophagitis.

The second category encompasses medications that neutralize stomach acid and protect the mucosal lining. For instance, sodium bicarbonate (baking soda) neutralizes stomach acid directly. Aluminum-magnesium compounds and aluminum carbonate magnesium preparations not only neutralize a portion of stomach acid but also adhere to the surface of the esophageal mucosa, forming a protective layer that aids in the healing of esophageal erosions.

The third category comprises prokinetic drugs, which enhance the gastric emptying rate, reduce food retention in the stomach, and, consequently, lower the risk of reflux.

The medication plan should be tailored according to the severity of the condition. For more severe cases, a combination of all three types of drugs is typically most effective; for milder cases, a single medication may be sufficient, with acid-suppressing drugs generally being the first choice. Most patients report significant symptom relief following treatment. The clinical guideline is: "If a single drug can manage the condition, do not resort to combination therapy." If one drug is insufficient, then consider using two or three drugs in combination.

It is crucial to acknowledge that the purchasing processes for certain acid-suppressing medications vary. Even for over-the-counter drugs, it is advisable to describe your symptoms to a doctor or pharmacist prior to purchase to prevent inappropriate medication use. If you have been using the medication for an extended period and your symptoms are consistent, you can directly purchase it at the pharmacy without repeatedly seeking a doctor's prescription.