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| Antacids used to be
the only medications available
until Tagamet and its family of
Hydrogen ion release blockers (H2R
blockers) such as Axid, Pepcid
and Zantac became available. Now
they can even be bought over the
counter in weaker doses. More
recently proton
pump inhibitors were
introduced that more effectively
reduce the acid production than
H2R blockers do. The first of the
proton pump inhibitors was
Prilosec followed by Prevacid and Aciphex. When Prilosec was first
introduced in the USA the FDA
restricted its use to short term
use not to exceed three months for
fear of developing stomach tumors
called carcinoids based on animal
experimentation results, this
requirement was later dropped. The
third line of medical treatment is
a family of drugs known as prokinetics
Clinically it has been found that when patients are moved up from H2R blockers to proton pump inhibitors, they cannot be returned to H2R blockers and expect any relief. This is probably because the use of such powerful acid suppressants as proton pump inhibitors induces the body to produce more acid producing cells, then when the less acid suppressive H2R blockers are used they cannot reduce the acid sufficiently to afford the patients relief. Both H2R blockers and proton pump inhibitors reduce the acid and relieve heartburn but patients continue to feel bile and food reflux with resulting pulmonary problems, Barrett esophagus and increase risk of cancer of the esophagus and of the stomach. Proton pump inhibitors, Prilesec, Prevacid and Aciphex reduce the acid production in the stomach more effectively than H2R blockers. This gives more effective relief from the symptom of heartburn, but they do not stop the reflux with all its damaging effect on the throat and lungs as well as the production of Barrett esophagus and cancer of the esophagus and stomach. In fact the epidemic rise of cancer of the esophagus almost coincided with their introduction. There is a theory that proton pump inhibitors reduce the acid levels so much, or just to the right level, that this increases the carcinogenic effect of bile. If this is ever proven there is no doubt in my mind that the FDA will go back to the severe restrictions they first had on Prilosec when it was first introduced. Prilosec could not be prescribed for long-term use over three months. The FDA dropped that because it was widely ignored and due to the experience overseas. There is no doubt that proton pump inhibitors are effective in reducing heartburn. So much so that patients who start on them cannot return to the less effective H2R blockers. This may be due to the increased number of acid producing cell stimulated by the use of proton pump inhibitors. The third line of medical treatment is a family of drugs known as prokinetics and as their name implies they improve the movement or function of the muscles of the esophagus, thereby clearing the esophagus of refluxed acid, bile and food. Logically and theoretically this group of medications should be the best line of medical treatment because it attempts to restore an impaired function or to improve a normal function. Unfortunately the two medications available at the present time in the USA have some major side effects. Reglan the medication first available has many side effects but most patients were unable to tolerate it due to the depression it produces and physicians were afraid to prescribe it on a long term basis due to its propensity to produce tardive dyskinesia a condition in which the face neck and body develop involuntary repetitive movements, something similar to parkinsonism but drug induced. Propulsid was initially hailed as the best line of medical treatment but its numerous side effect of changes in the heart wave, numerous interactions with medications and even with grapefruit prompted the FDA to have the company issue an alert to all medical professionals and to the media 0n January 25th., 2000. March 24, 2000 there was an even more dramatic announcement by the manufacturer of Propulsid that the drug will be taken off the market.. DRAWBACKS OF MEDICAL TREATMENT The major drawback of all these medications is that they have to be used forever and once they are stopped the symptoms recur. The recent demonstration that the eight fold increase in esophageal adenocarcinoma and the two fold increase of cancer of the stomach is not reduced by medical treatment is probably the biggest testimonial against prolonged medical treatment and in favor of surgical intervention in these cases. Even before the information about cancer was known, prestigious gastroenterologists with particular expertise in diseases of the esophagus have stated: "Only antireflux surgery can cure gastro esophageal reflux disease. Major indications for surgery include younger patient age requiring expensive long term medical therapy, nonhealing esophageal ulcer, difficult-to-manage peptic stricture, severe bleeding from esophagitis, and persistent symptoms of micro aspiration of gastric contents."
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