Trouble with all PPI's

[esimpkins]

Has anyone had trouble taking all the PPI's (Nexium, Prevacid, Aciphex, Protonix)?

I have been trying to stay on my prescribed dosage of two a day prescribed for LPR. I get terrible headaches, anxiety and sleepiness. In addition my extraesophageal symptoms (I don't really ever get heartburn), throat problems, sinus problems, chest pressure and pain do not seem to improve

I have had an endoscopy which showed mild to moderate inflamation at the LES juncture and and PH montior that showed severe reflux.

Due to the severe reflux shown on the probe and my lack of tolerance for the PPI's, I am currently scheduled for fundo surgery next month.

Is there any other medication I should try before what seems like the last ditch effort of surgery

[PWagenbret]

I've had trouble with PPIs, too, though not the sort you describe -- mostly abdominal cramping for me. Right now, at my request, my doctor has me on the lowest possible dosage of prescription Prilosec.

I've read where a muscle relaxant, baclofen, has proven successful in treating GERD, specifically in bolstering the LES. I don't know if it's currently being prescribed for GERD, though -- I gather that usage is still being researched. You might look into it, though. Maybe your doctor knows something about it.

I'd be interested in knowing anything you find out. Good luck.

[daw]

Have you ever tried a prescription strength H2Blocker (Pepcid, Zantac, etc.) or a Prokinetic like Reglan? I know the PPIs are suppose to be the best defense but some people do not respond to them. My symptoms were not relieved until I took Pepcid 40mg twice a day. It's worth a try.

[tricia]

April 21, 2003 — Baclofen acutely reduces symptoms and episodes of gastroesophageal reflux disease (GERD) and raises gastric pH, according to the results of a study published in the April issue of Gut. Symptomatic improvement continued for the four weeks of the study, which suggests that this may be a viable alternative treatment for GERD. Baclofen is approved by the Food and Drug Administration, but not for this indication.

"In normal human subjects and in patients with [GERD], recent studies have shown that baclofen reduces the rate of transient lower oesophageal sphincter relaxations, the rate of gastro-oesophageal acid reflux episodes, and increases basal lower oesophageal sphincter pressure," write A. F. Ciccaglione and L. Marzio from the University G d' Annunzio, in Chieti-Pescara, Italy. "Baclofen therefore has been proposed as potentially useful in the treatment of [GERD]."

In a double-blinded acute study, 28 patients with GERD with no esophagitis or mild esophagitis at endoscopy and 15 controls had 48-hour esophageal and gastric pH monitoring. During monitoring, they received baclofen or placebo, each for 24 hours. The number of reflux episodes and percentage of time with pH less than 4 was significantly lower with baclofen than with placebo in GERD patients (P < .003) and in controls (P < .0007). During baclofen administration, gastric pH increased significantly in GERD patients (P < .001) and in controls (P < .05).

In a longer-term study, 16 patients with GERD received baclofen, 10 mg four times daily, or placebo for four weeks. All patients receiving baclofen had a significant decrease in the number of reflux episodes (P < .003) and the percentage of time with pH less than 4 (P < .02), and symptom scores significantly improved (P < .0007).

"Current pharmacological treatment of [GERD] is based on acid suppression with anti-H2 receptor antagonists or proton pump inhibitors, or both. Drugs that have less activity on acid secretion have also been evaluated with various results," the authors write. "The improvement in reflux parameters and of symptoms related to gastro-oesophageal reflux in patients with [GERD] treated for four weeks with baclofen suggest a potential therapeutic role for this drug in the treatment of gastro-oesophageal reflux disease."

Clinical Context

GABA (-aminobutyric acid) is a potent inhibitory neurotransmitter in the central nervous system; it antagonizes the release of neurotransmitters from vagal nerve afferents through its GABAB receptor. Physiologic and pharmacologic studies in animals have shown that activation of GABA receptors with the GABAB agonist baclofen inhibits transient lower esophageal sphincter relaxation, gastroesophageal reflux, and gastric secretion.

Gut. 2003;52:464-470