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Gastroesophageal reflux disease (GERD) or acid reflux is a generally chronic condition characterized by the regurgitation of stomach acid, pepsin and sometimes bile into the esophagus. This can cause damage and inflammation of the esophagus lining. While the acid is considered the most harmful component of this regurgitation, pepsin and bile can also injure the esophagus. However, their role in the inflammation and damage of the esophagus is not fully elucidated. While the direct cause of GERD is not fully understood, certain factors can contribute the development of GERD. These factors include:
- Lower esophageal sphincter abnormalities – both the weak contraction of the lower esophageal sphincter which reduces the ability to prevent reflux and the abnormal relaxation of the lower esophageal sphincter have been identified in patients with GERD.
- Hiatal hernias – a high proportion of patients with hiatal hernias suffer from GERD. Studies have suggested that hernial sacs, small pouches of the stomach above the diaphragm, can trap acid close to the esophagus, thus making it easier for acid reflux to occur. Moreover, it is also suggested that hiatal hernias can alter the angle in which the esophagus enters the stomach which can make the esophagus more susceptible to acid reflux. However, little is truly known why there is an association between incidence of hiatal hernias and GERD.
- Medical conditions – elevated hormone during pregnancy can cause acid reflux by lowering the pressure of the lower esophageal sphincter. Moreover, a growing fetus can put pressure on the abdomen and contribute to acid reflux. In addition, patients with diseases causing weakened esophageal muscles such as scleroderma are more prone to develop GERD.
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Acid reflux treatment options
Since acid reflux has a toll on a large proportion of the population, its treatment is essential. This article will focus on two major treatment options, Nexium® and Zantac® and the benefits and risks of using Nexium and Zantac together to treat acid reflux. But before focussing on these two treatments, let’s better understand the general treatment options available for acid reflux. These include:
- Proton pump inhibitors – act by blocking the production of the enzymes required to produce stomach acid. These include brands such as; Prilosec, Nexium, Prevacid, Aciphex and Protonix.
- H2 blockers – act by blocking the action of histamine in the parietal cells of the stomach by decreasing the production of stomach acid. An example of a H2 blocker is Zantac.
- Coating agents – act by coating the mucosal membranes and sores of the esophagus. This creates an additional protective barrier against stomach acid. An example of these is Carafate.
- Pro-motility agents – act by tightening the lower esophageal sphincter and promoting faster emptying of the stomach. Examples include: Reglan, Clopra, Maxolon, Duvoid and Urabeth.
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What is Nexium?
Nexium, chemical name esomeprazole, is a proton pump inhibitor that decreases the amount of acid produced in the stomach. It is indicated for the treatment of symptoms of GERD and other conditions that involve the excessive production of stomach acid such as Zollinger-Ellison syndrome. It has also been shown to promote the healing of eroded esophageal lining, prevent gastric ulcers induced by non-steroidal ant-inflammatory drugs (NSAIDs) and prevent gastric ulcers in patients inflected by H. pylori. It is important to note that Nexium is a long-term mediator of acid reflux and is not effective in the immediate relief of heartburn symptoms. Like all medications, Nexium is associated with side effects such as headache, drowsiness, diarrhea, nausea, stomach pain, gas, constipation and dry mouth.
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What is Zantac?
Zantac is a H2 blocker used in the reduction of stomach acid production and irritation of the stomach lining, as well as assist in the healing of gastric ulcers and other gastrointestinal conditions. Specifically it is indicated for the short-term treatment of active ulcers of the stomach or duodenum, the prevention of reoccurring ulcers, treatment of conditions characterized by increased stomach acid production, treatment of GERD and the treatment and healing of erosive esophagitis. Its most common side effect is headache, in which some cases headaches were reported to be severe.
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The benefits and risks of Nexium and Zantac
Both H2 blockers (Zantac) and proton pump inhibitors (Nexium) have been shown to be effective in the suppression of the secretion of basal gastric acid. While H2-blockers are known for their rapid onset of action (within 1 hour) and short relief duration (less than 12 hours), proton pump inhibitors have been shown to have a delayed onset of action with a prolonged symptom relief duration (up to 3 days). Thus before deciding on which therapeutic option best suits a patient, consider the both the advantages and disadvantages of selecting either treatment option.
The benefits and risks of Nexium therapy:
The major benefit of Nexium over Zantac is that proton pump inhibitors have been shown to have a superior symptom relief compared to H2 blockers. In fact, studies have shown that proton pump inhibitors significantly relieve symptoms compared to H2 blockers in the initial therapy of uninvestigated GERD (75 percent vs. 58 percent), heartburn relief at 4 weeks in endoscopically negative reflux disease patients (53 percent vs. 42 percent) and uninvestigated dyspepsia symptom relief at 4 weeks (23 percent vs. 11 percent).
Although proton pump inhibitors have been shown to have a relatively good safety profile, there is recent evidence suggesting that they are associated with an increased risk of hip fracture related to a decrease in calcium absorption with acid suppression. Secondly, the suppression of gastric acid has been associated with a decreased destruction of ingested pathogens and an association between proton pump inhibition and community acquired pneumonia has been identified. Furthermore, observational studies have claimed an association between in proton pump inhibitor use and Clostridium difficile associated diarrhea. However, No significant correlation has yet to be made.
The benefits and risks of Zantac therapy:
While studies have shown that proton pump inhibitors are more effective than H2 blockers, there are certain conditions or circumstances in which less intense acid suppression of H2 blockers would be considered a reasonable option, depending on the level of symptom severity. Moreover, they are also a less costly option for many patients compared to proton pump inhibitors and they have been shown to control symptoms in almost 60% of GERD patient. Additionally, its faster onset of action makes it a favorable by many patients.
Its major downfall of H2 blockers is its reduced effectiveness. In fact, a study demonstrated that H2 blockers rarely provide complete symptoms relief of chronic heartburn and dyspepsia and do not reduce physician visits for GERD-like complaints. Moreover, these agents provide no protection against Barrett's esophagus and their use may cause cancerous changes in the stomach in patients who are infected with H. pylori.
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Are there any benefits of combining Nexium and Zantac?
While little is actually known to the benefits and risk of prescribing a patient a combination of proton pump inhibitors and H2 blockers, some doctors recommend a night dose of an H2 blocker for patients taking bi-daily proton-pump inhibitors. The reason for this is because it is believed that this addition of an H2 blocker will help prevent a rise in acid reflux at night. However, a study has demonstrated that there were no additional benefits the addition of H2 blockers in the prevention of night acid reflux. Furthermore, other doctors recommend that H2 Blockers are used following a heavy meal and minimize the risk of heartburn and acid reflux. However, the benefits of meal time H2 blockers have yet to be studied. Thus, future studies are required to determine whether there are any benefits of using Nexium and Zantac together to treat acid reflux.
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Medicine Health - http://www.emedicinehealth.com/reflux_disease_gerd/article_em.htm
Nexium Prescribing Information - http://www1.astrazeneca-us.com/pi/Nexium.pdf
Zantac Prescribing Information - http://us.gsk.com/products/assets/us_zantac.pdf
Richards, Goltzman. Proton pump inhibitors: balancing the benefits and potential fracture risks. CMAJ. 2008;179: 306.
Newfoundland Health -http://www.health.gov.nl.ca/health/prescription/benefitstatuschangeforppis.pdf
® Zantac is a registered trademark of Warner-Lambert Company; Nexium is a trademark of AstraZeneca AB.