Antacids and alginate in the step-down process and as monotherapy

This article expands on the continuing education article “Gastroesophageal reflux disease” on the aspect of alternative treatment for PPI intolerance or discontinuation of the PPI medication. Proton pump inhibitors (PPIs) are among the most commonly prescribed medications. They are used in the treatment of gastroesophageal reflux disease (GERD), but also in gastroduodenal ulcers. Because PPIs are well tolerated overall, the potential long-term side effects are often disregarded and no other treatment options are considered. The widespread use of PPI should be critically questioned and alternatives should be weighed.

According to the current drug report of the Swiss health insurance company Helsana, pantoprazole is among the five most frequently purchased PPI agents [1]. However, according to studies, in many cases they are prescribed without the necessary indication and about 40-80% of PPI prescriptions are not guideline compliant [2].

One problem in this context is over-the-counter access to certain low-dose PPI preparations [4]. At this point, it is particularly important to inform patients about possible side effects and increase in symptoms after discontinuation of the medication.

Antacids and alginate in the long-term therapy of GERD.

Although PPIs are mostly well tolerated, side effects can occur and the consequences of long-term therapy are difficult to assess. Nevertheless, PPI are usually used for prolonged or permanent treatment of GERD. However, a gradual dose reduction should be used to determine the lowest effective dose in order to minimize the risk of adverse effects. In case of long-term stable remission under continuous PPI therapy, even a discontinuation attempt can be made [5].

Both during gradual dose reduction, the so-called step-down process, and when discontinuing PPIs in the step-off process, additional symptom-oriented treatment is useful. As shown in placebo-controlled studies in healthy subjects, abrupt discontinuation of PPI after four or eight weeks of treatment results in acid rebound with an increased risk of dyspeptic symptoms [6,7]. Although the value of these outcomes in patients with reflux disease is controversial, the risk for symptomatic acid rebound should still be minimized. For this reason, in addition to gradual dose reduction, the use of an antacid or alginate as needed is advised. In an observational study in 27 English GP practices, it was shown that treatment with alginate in the step-down or step-off process has a success rate of about 80% [8].

Treatment of GERD patients who do not want PPI.

Public awareness of the overuse of PPIs and the potential side effects of these drugs in long-term therapy has resulted in patients becoming increasingly critical of the prescription of such a drug. A number of alternative treatment options are available to meet the needs of these patients. These include various drug, endoscopic, or surgical interventions [9]. Among drug therapy options, antacids and alginate are the most important. Compared with placebo, treatment with antacids results in a relative improvement in symptoms of up to 11%, and alginate-antacid combination preparations can achieve an improvement of up to 60% [10]. Thus, other effective treatment options for GERD are available in addition to PPIs. The efficacy of alginate in relieving GERD symptoms is superior to that of antacids in this regard [11].

Apart from the side effects, the onset of action also plays a decisive role for many patients. Younger people in particular often do not want to take medication permanently, but only on an as-needed basis. However, especially in patients who use antireflux medications only for acute gastric distress, the use of PPI is not reasonable due to the time that elapses from intake to the onset of maximal effect [9]. Therefore, to treat postprandial stomach burn quickly, antacids or alginate are better options. Antacids neutralize stomach acid as soon as they come into contact with it, so that their effect occurs within less than twenty minutes [12]. The alginate preparation ^Gaviscon® leads to effective relief of symptoms after less than four minutes, with the protective barrier formed by the alginate remaining in place for more than four hours [13,14]. Thus, a quick and long-lasting effect of the treatment is enabled.

Alternative treatment options for patients with PPI intolerance.

In patients with PPI intolerance or when PPIs must be temporarily discontinued, it is possible to switch to monotherapy with antacids or alginate. Treatment with antacids can relieve gastric burning and reduce acid regurgitation [15,16]. However, a direct effect on the occurrence of reflux episodes can only be achieved with alginate preparations, as their unique mechanism of action creates a physical protective barrier in front of the gastroesophageal junction. This can also significantly reduce the symptoms of stomach burning, regurgitation and dyspepsia [17]. This is true regardless of whether it is an erosive or non-erosive manifestation of GERD [18]. Overall, the efficacy of alginate in particular is supported by an extensive evidence base, and compared with conventional antacids, alginate shows a more effective effect [11,19]. In patients with NERD or moderate GERD, an effect size comparable to PPIs was even observed with regard to symptom control [20,21]. In addition, the long-term safety profile shows that alginate has very few side effects and is well tolerated. The most common side effects include gastrointestinal symptoms such as constipation, abdominal distention, bloating or nausea [18].

Alginate enables effective reflux suppression through its mechanism of action. It forms a physical protective barrier in front of the gastroesophageal junction and thus prevents reflux directly at the point of origin. Since it is not metabolized and is therefore excreted unchanged, it has very few side effects and is well tolerated by most patients. Thus, no systemic interactions with other drugs are known.

Take-Home Messages

PPIs should be prescribed only when sufficiently indicated.
For long-term therapy of GERD, the lowest effective PPI dose should be determined.
In the step-down process, antacids and alginate are helpful for symptom control.
In patients who do not want or cannot tolerate PPI treatment, antacids and alginate are good alternatives.
Alginate provides more effective reflux suppression than antacids.