What is the next best suggestion for a patient with induced laryngeal occlusion, on long-term ventilation, suffering from gastroesophageal reflux disease (GERD), who refuses Gaviscon (alginic acid) due to its liquid formulation?

From the Guidelines

For a patient with induced laryngeal occlusion who is long-term ventilated, suffers from reflux, and refuses Gaviscon due to its liquid form, I would recommend a tablet form of a histamine-2 (H2) receptor antagonist, such as ranitidine, as the next best option. This is because the patient's refusal of Gaviscon is based on its liquid form, and an alternative that can be easily administered in a solid form is necessary. According to the American Gastroenterological Association's medical position statement on the management of gastroesophageal reflux disease 1, lifestyle modifications can be beneficial for patients with GERD, but in this case, a pharmacological approach may be more appropriate due to the patient's specific situation.

• The patient's condition as a long-term ventilated individual with induced laryngeal occlusion and suffering from reflux necessitates a treatment approach that not only manages symptoms but also considers the risk of aspiration.
• Ranitidine, being an H2 receptor antagonist, can reduce acid production in the stomach, thus alleviating reflux symptoms.
• Additionally, non-pharmacological measures such as elevating the head of the bed by 30-45 degrees, as suggested by 1, can help reduce esophageal acid exposure and should be considered alongside pharmacological treatment.
• It's also important to note that while proton pump inhibitors (PPIs) are effective in reducing acid production, the patient's specific refusal of a liquid medication form and the availability of ranitidine in a solid form make it a more suitable next option in this scenario.

From the FDA Drug Label

For patients who have difficulty swallowing capsules, lansoprazole delayed-release capsules can be opened and administered orally or via a nasogastric tube in the soft foods or liquids specified below Administration in Soft Foods (applesauce, ENSURE pudding, cottage cheese, yogurt or strained pears ): Open capsule Sprinkle intact pellets on one tablespoon of either applesauce, ENSURE pudding, cottage cheese, yogurt or strained pears. Administration in Liquids (apple juice, orange juice or tomato juice): Open capsule Sprinkle intact pellets into a small volume of either apple juice, orange juice or tomato juice (60 mL – approximately two ounces).

The next best suggestion for a patient who refuses to take Gaviscon due to its liquid form is lansoprazole in a solid form, which can be administered in soft foods like applesauce, ENSURE pudding, cottage cheese, yogurt, or strained pears, or in liquids like apple juice, orange juice, or tomato juice 2.

• Key benefits:
  • Can be administered in various forms to accommodate patient preferences
  • Available in delayed-release capsules that can be opened and mixed with soft foods or liquids
• Important considerations:
  • Should be taken before meals
  • Should not be crushed or chewed
  • Missed doses should be administered as soon as possible, but not taken with the next scheduled dose.

From the Research

Patient Refusal of Gaviscon

The patient's refusal of Gaviscon due to its liquid form presents a challenge in managing their reflux symptoms.

• The patient's condition of induced laryngeal occlusion and long-term ventilation, combined with reflux, requires careful consideration of treatment options.
• According to the study 3, Gaviscon Advance alone is effective in treating symptoms of laryngopharyngeal reflux, and co-prescription with a proton pump inhibitor (PPI) offers no additional benefit.

Alternative Treatment Options

Considering the patient's refusal of Gaviscon, alternative treatment options can be explored:

• Proton pump inhibitors (PPIs) such as lansoprazole, rabeprazole, and pantoprazole have been shown to be effective in treating gastroesophageal reflux disease (GERD) 4.
• The study 5 provides updated, evidence-based recommendations for the evaluation and management of GERD, including pharmacologic, lifestyle, surgical, and endoscopic management.

Management of Reflux in Intubated Patients

The patient's history of intubation and reflux symptoms is relevant, as gastroesophageal reflux has been identified as a potential factor in laryngeal complications of intubation 6.

• Monitoring of pharyngeal pH and initiation of treatment for gastroesophageal reflux may be necessary to prevent permanent laryngeal and tracheal injury.

Next Best Suggestion

Given the patient's refusal of Gaviscon, a suitable alternative could be a proton pump inhibitor (PPI) in tablet form, such as lansoprazole or rabeprazole, as these have been shown to be effective in treating GERD 4.