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LTC Pharmacy Notes: A Look at GERD Treatment Recommendations

Gastroesophageal reflux disease (GERD), which develops when stomach acid frequently flows back into the esophagus, is common in long-term care residents. Similar to other conditions, older adults are at a higher risk of complications from chronic GERD, making it important for long-term care providers—including LTC pharmacy services—to stay up to date on the condition. Some common medications used to treat GERD in residents include antacids, histamine 2-receptor antagonists, and proton pump inhibitors. While these medications are readily available and effective at relieving symptoms, there are a number of lifestyle modifications that can also help. Many of these modifications can be used in conjunction with medications to provide residents with optimal outcomes. [Tweet “#GERD is a common medical condition in older adults, including #SkilledNursing Facility residents.”]

LTC Pharmacy Notes: Lifestyle Changes for Treating GERD

Before resorting to pharmacologic treatment, it’s wise to see if certain lifestyle modifications help improve GERD symptoms in skilled nursing residents. There are two particular lifestyle modifications with the strongest amount of evidence: weight loss and head-of-bed elevation. Though weight loss may not be the answer for residents—who are at increased risk of nutritional deficiencies—long-term care providers can reduce GERD symptoms in residents by simply elevating the resident’s head using foam blocks or an extra pillow. In addition, a handful of other lifestyle changes that can help with GERD include:
  • restricting food intake two to three hours before bed
  • avoiding spicy foods
  • limiting foods with high fat content

LTC Pharmacy Notes: Medications for Treating GERD

Pharmacologic options do have their place in the treatment of GERD. However, it’s important that they be used as a preventive measure, rather than a responsive one. GERD medications are designed to reduce the acidity of the stomach. There are three primary categories of medications for treating GERD:
  • antacids
  • histamine 2-receptor antagonists (H2RAs)
  • proton pump inhibitors (PPIs)
Let’s take a closer look at each category and their implications for SNF residents. Antacids, such as Tums®, Rolaids®, and Maalox®, are designed to be given after symptoms present and provide symptomatic relief for up to an hour. Since they do not contribute to healing erosive esophagitis, they are not recommended as first-line treatment for GERD. Instead, antacids are a solid option for treating infrequent episodes of mild reflux. Additionally, antacids can be used for residents with identified triggers or for relief of breakthrough symptoms. H2RAs, like Pepcid® and Zantac®, are more effective than antacids. These medications are renally dosed and used as a maintenance option in residents who have milder forms of GERD or GERD symptoms without erosive esophagitis. Histamine 2-receptor antagonists may be given with or without food. However, to prevent GERD symptoms from occurring, it’s recommended that they be taken about a half hour prior to eating foods that can exacerbate symptoms. Additionally, if a resident still requires GERD therapy, H2RAs may be used concurrently with PPIs, as the efficacy of H2RAs may decrease after three to four weeks of use. Notably, there are some side effects associated with H2RAs, which include:
  • CBC abnormalities
  • liver function irregularities
  • headaches
PPIs, which include medications like Protonix® and Prilosec®, are the most potent acid-suppressing agent. Having shown greater efficacy than H2RAs, PPIs have become the standard of treatment for GERD.   For maximum efficacy, this class of medications should be taken 30 to 60 minutes before the first meal of the day. If residents do not experience relief, 20mg of Prilosec may be administered twice daily for GERD. The recommended length of treatment is four to eight weeks. With PPIs’ potency also comes several long-term side effects. These include:
  • Clostridium difficile-associated diarrhea
  • pneumonia
  • bone fractures
  • rebound hypersecretion
  • hypomagnesemia
  • vitamin B12 deficiency
  • drug interactions
In addition, it’s worth noting that some alternative agents may be effective in refractory residents. For example, though there’s limited supporting evidence, metoclopramide, baclofen, and melatonin are three off-label alternatives that are sometimes used to treat GERD in residents.

LTC Pharmacy Endnotes on GERD Treatment Recommendations

Ultimately, it’s vitally important that residents have documented indications for all medications in their charts. Too often, medications for GERD are started in the hospital as prophylaxis and are continued once residents are back in a long-term care setting. This makes it essential to check a resident’s history and re-assess the need for GERD treatment. By working together and properly following treatment guidelines, we can alleviate symptoms of GERD in SNF residents, and, ultimately, improve their health outcomes. The Grane Rx team stays up-to-date on the latest information related to long-term care pharmacy—and passes that knowledge along to your team. Call (866) 824-MEDS (6337) or fill out this quick form to find out how your SNF could benefit.]]>

Picture of Jennifer Devinney, RPh, PharmD

Jennifer Devinney, RPh, PharmD

Jennifer Devinney is the Chief Clinical Officer for Grane Rx. In this role, she works with clinical pharmacists and nurses in conjunction with facility staff to develop and oversee clinical initiatives. Additionally, she is the clinical EHR integration specialist.

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