Steve Morris: Well, first of all, there is what we call the life style changes or life style modification. That’s really the basic building blocks upon which we build our other therapy. The first of these may if the patient is overweight to try and slim down and achieving more normal body weight. Second would be diet. We know that there are certain dietary factors that can predispose towards reflux, particularly let’s say, a high-fat diet affects the lower Esophageal Sphincter. Low is the pressure that’s the barrier between this esophagus and the stomach, allows more reflux so there can be dietary modifications. Not only the content of the diet but actually the timing of the intake.
For example, we tell patients not to eat late at night before they go to sleep because the consequence of eating is the production of acidity. So if you eat late at night, you increase the amount of acid that your stomach produces and then this results of a lot of acid and volume in the stomach while you’re ready to lie down. Another thing is not lying down during the day after you’re eating. So those are some of the things we can do as far as diet and life-style modification. Stopping smoking, not drinking a lot of caffeine are also modifications that are beneficial. Once we get past the life style modifications, then we’re into what we term medical therapy.
Robert Bresalier: There is a spectrum fortunately of medications that can treat reflux and you can really break them down into categories of drugs. The most simple thing is something that neutralizes acid; antacid is obviously have been around for long time and for somebody with the occasional symptoms who is awake, taking some antacids, maybe helpful symptomatically.
Steve Morris: If the symptoms however are recurrent, they are not simply relived with the use of an antacid or you are having to use antacids quite frequently or f there are certainly any of what we term alarm symptoms, if these are associated with heart burns and weight loss, some difficulty swallowing, waking up frequently at night, any of these are alarm symptoms that we look for, and of course, a doctor should be consulted quite soon.
Robert Bresalier: Then there are, what we call, H2 or Histamine-2 receptor antagonists. These block one of the receptors on the cell in the stomach that produces acid and they are good mild-to-moderate symptoms and reflux.
Steve Morris: The treatment of ulcer disease was well-served by the H2 receptor blockers because it appears that the stimulation of acid by histamine was critical in the production of ulcers and then we also found an associated bacteria associated with ulcer is that we can now eradicate. However, in the product, in the treatment of reflux, it is much more difficult. It’s a more difficult problem, it’s a chronic problem and the elimination of acid has to be much more total than in the production -- than in the treatment of Ulcers.
Robert Bresalier: The newest group of drugs; they’ve been around for over a decade in the United States are so called Proton Pump Inhibitors. Their importance is no matter what stimulates the acid secretion; they block the final pathway of acid secretion. That’s why they’re such good and potent drugs. These are very effective in treating all varieties of reflux disease.
Steve Morris: What you look for in the treatment of Nighttime GERD is a medication that obviously lasts longer. For example, the drugs are mostly all given in the morning and what you want to do is trying block these proton pumps as they become active during the day and all of these medications are strived to last for a 24-hour period and the recommended dosage is one today in the morning.
Robert Bresalier: I think that there are some newer proton pump inhibitors on the market which to some extent to cover a greater area of the night time period in terms of your ability to inhibit acid for different reasons and I think that there has been some evolution such as we’ve produced these really designer drugs for reflux; we’ve been doing a better job of treating both day time and nighttime reflux.
Steve Morris: Some of the medications appeared to have a longer half-life certainly testing in laboratory situations such as pantoprazole because of the receptors that it may block. So therefore, there may be some rationale for using that particularly in the treatment of nighttime or nocturnal gastritis -- reflux.
Robert Bresalier: Really when we treat reflux I think we want to do three things. We want to heal the disease and keep it healed. We want to make people feel better and that’s obviously what as individual most interesting, they want to feel better and we want to prevent complications. And those are the really the three major goals. The drugs we have, especially the proton pump inhibitors and really quite good at achieving those goals. We can heal inflammation and erosion, even ulceration in vast majority of patients. Some patients will go on to have scarring and the test be dealt with in a different manner, but with the vast majority of people, we can heal and maintain that healing of damage. Most people will feel remarkably better when taking these drugs so the typical and atypical symptoms will go away. Then is issue of complications. Certainly, if we heal erosions and ulcers we can prevent structuring or scarring to the esophagus. We can prevent bleeding and we hope to prevent what is one of the most concerning things about reflux is development of cancer in the esophagus.
Steve Morris: We know that with proper treatment you can reverse most of this damage and get back towards a normal esophagus. We also know that when you stop the treatment, a lot of this damage can reoccur fairly rapidly.
Robert Bresalier: The good news is for both healing and symptoms, probably over 90% of individuals will respond quite well to the proton pump inhibitors both with healing and with the also stay and symptom relief. More recently a number of endoscopic procedures have come about where you can look down at the esophagus and perform a variety of manipulations when it’s almost like a little sewing machine.
Steve Morris: The Enteryx is a newer treatment and that’s an injection of a collagen like substance into the gastroesophageal junction and this injection is also supposed to remodel the area, tighten the sphincter and prevent reflux.
Robert Bresalier: The other creates a high-frequency radio wave to create some tightening of that area. These are actually in clinical practice.
Steve Morris: The stator procedure is a radio frequency procedure administrated thorough a catheter and special radio-frequency device and it’s administrated at the gastroesophageal junction to try and tighten the sphincter and also to what we call reconfigure the area so that it’s more resistant to reflux.
Robert Bresalier: I think we still have ways to go to prove that these are effective measures but certainly things like Laparoscopic Fundoplication have been around for a long time in our options.
Steve Morris: I think the important thing is if they do have Nighttime GERD, they probably need to see a physician because it’s more than just your average symptom at that time. And then the import thing is to get to life style modifications as we discussed or important part is therapy and then being on the proper medication and also taking the medication properly. A lot of times people take their medication late in the day instead of taking it first thing in the morning, depending on which PPI they are on and food can inhibit the absorptions, they need to take it correctly in relation to their first meal of the day. If they’re not doing better with that then the doctor can add either a second dose in the evening or adding another medication what we call a promotility agent in the evening. So they should not just accept it as a normal state of existence because there really are good medications today that can treat it very effectively.
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