Alginates offer an alternative option for the treatment of reflux symptoms and are the drug of choice for pregnant women with reflux symptoms. The new version of the “S2k guideline on gastroesophageal reflux disease and eosinophilic esophagitis” published by the German Society of Gastroenterology, Digestive and Metabolic Diseases (DGVS) in March 2023 upgrades alginates and recommends them for a wide range of indications.1
Gastroesophageal reflux disease (GERD) is common worldwide and affects up to 25% of people in Europe.2 The standard treatment is to take proton pump inhibitors (PPI).1 In its current S2k guideline, the DGVS now mentions the use of alginates (Gaviscon®) in several indications.1 This natural ingredient from algae forms a barrier at the gastro-oesophageal junction/sphincter, preventing stomach acid and stomach contents from rising. The acid pocket formed postprandially in the fundus, which represents a reservoir for acid reflux, can thus be neutralized by alginates.3
Diagnosis of GERD
GERD is mentioned in the new guideline as the most common cause of non-cardiac chest pain.1 According to the Montreal Classification, which is cited in the guideline, GERD is present when the patient experiences symptoms and/or lesions in the esophagus due to reflux of gastric contents into the esophagus, which are attributed to acid exposure.1 The updated guideline emphasizes that a generous indication for endoscopy can be given if there is a patient request or the classification of the symptoms is unclear.1 However, an endoscopy not only provides diagnostic information but, according to studies, can also reassure anxious patients.4
Therapy of GERD – now also with alginates
The standard therapy for GERD is treatment with PPI for at least 4 to 8 weeks.1 Patients without risk factors for complications, without a family history of upper digestive tract malignancies and with typical symptoms without alarm symptoms can be treated empirically with an alginate as long as sufficient symptom control is achieved. If a standard PPI dose is used primarily and symptom control is insufficient, the guideline now states that combination therapy with an alginate up to 4 times a day can also be considered.1 If laryngo-pharyngeal reflux is suspected, which can be the cause of an extra-oesophageal manifestation of GERD and can manifest itself as a cough or laryngitis, for example, PPI therapy at twice the standard dose is primarily recommended in adults.1 Based on preliminary study data highlighting the efficacy of alginates compared to no treatment, the updated guideline now mentions alginates as a possible treatment option for laryngo-pharyngeal reflux for the first time.1 Alginates are also listed as an alternative to PPI for nocturnal GERD.1 They can be taken immediately before bedtime and can increase the number of symptom-free nights in patients with insufficient PPI effect and reduce GERD-associated sleep disturbances.5, 6
Alginates when tapering off PPI therapy
The guideline recommends regularly reviewing the need for PPI treatment for GERD and discontinuing treatment if necessary, unless the GERD is complicated (bleeding has occurred, acid-related esophageal stenosis).1 Stopping PPI therapy often leads to a temporary increase in acid production in the stomach (acid rebound), which can last for several weeks and lead to dyspeptic symptoms. The risk of an acid rebound depends on the duration of the previous PPI therapy.7 A step-down to H2 receptor antagonists to bypass the acid rebound is not recommended, and they are not currently available in Switzerland.1 In this context, the guideline emphasizes the effectiveness of alginates: By taking alginates, 75.1% of patients with dyspepsia and long-term PPI therapy were able to reduce their PPI dose within one year and 40.3% were able to stop it completely.1, 8
Possible use of alginates during pregnancy and for NERD
Alginates have proven to be effective and safe, particularly in the step-up management of reflux symptoms during pregnancy.9 Alginates have therefore been recommended since 2014 for pregnant patients for whom general lifestyle measures are not effective.1, 10
In the treatment of non-erosive reflux disease (NERD), unexplained GERD without risk factors or mild reflux esophagitis, on-demand therapy with PPIs has historically been the treatment of choice. Meanwhile, the use of alternative medications led to satisfactory symptom control in a relevant proportion of patients, which is why the updated guideline now advocates treatment with alginates or antacids if patients are satisfied with symptom control.
Expert statement by Prof. Dr. med. Daniel Pohl, Senior Physician, Department of Gastroenterology and Hepatology, University Hospital Zurich
With the inclusion of alginates in the updated DGVS guideline, the solid data situation regarding effectiveness and low side effects in the treatment of gastroesophageal reflux disease is now taken into account. This is particularly important for those patients who want a natural and needs-oriented treatment, either as a substitute for uncomplicated reflux disease or in addition to PPI therapy, but also for patients who suffer from side effects due to PPI intake or who do not respond adequately to PPI alone.
References
1 German Society for Gastroenterology, Digestive and Metabolic Diseases (DGVS; ed.). S2k guideline Gastroesophageal reflux disease and eosinophilic esophagitis of the German Society of Gastroenterology, Digestive and Metabolic Diseases (DGVS) from March 2023 – AWMF register number: 021-013. Z Gastroenterol, 2023. 61(7): p. 862-933.
2 El-Serag HB et al. Update on the epidemiology of gastro-oesophageal reflux disease: a systematic review.Gut, 2014. 63(6): p. 871-80.
3 Deraman MA et al. Randomized clinical trial: the effectiveness of Gaviscon Advance vs non-alginate antacid in suppression of acid pocket and post-prandial reflux in obese individuals after late-night supper. Aliment Pharmacol Ther, 2020. 51(11): p. 1014-1021.
4 García-Altés A et al. Cost-effectiveness of a ‘score and scope’ strategy for the management of dyspepsia.Eur J Gastroenterol Hepatol, 2005. 17(7): p. 709-19.
5 Reimer C et al. Randomized clinical trial: alginate (Gaviscon Advance) vs. placebo as add-on therapy in reflux patients with inadequate response to a once daily proton pump inhibitor. Aliment Pharmacol Ther, 2016. 43(8): p. 899-909.
6 Müller M et al. [Alginate on demand as add-on for patients with gastro-oesophageal reflux disease and insufficient PPI effect]. Dtsch Med Wochenschr, 2019. 144(4): p. e30-e35.
7 Ruigómez A et al. Esophageal stricture: incidence, treatment patterns, and recurrence rate. Am J Gastroenterol, 2006. 101(12): p. 2685-92.
8 Coyle C et al. Sustained proton pump inhibitor deprescribing among dyspeptic patients in general practice: a return to self-management through a program of education and alginate rescue therapy. A prospective interventional study. BJGP Open, 2019. 3(3).
9 Thélin CS et al. Review article: the management of heartburn during pregnancy and lactation. Aliment Pharmacol Ther, 2020. 51(4): p. 421-434.
10 Koop H et al. S2k guideline: gastroesophageal reflux disease guided by the German Society of Gastroenterology: AWMF register no. 021-013. Z Gastroenterol, 2014. 52(11): p. 1299-346.
43257 NOV 2023
Dr. sc. ETH Kristina Thumfart
This article was produced with the financial support of Gaviscon, Reckitt (Switzerland) AG.
You can find the current technical information on Gaviscon® at www.swissmedicinfo.ch
Contribution online since 30.11.2023
