Would a proton pump inhibitor (PPI) and metoclopramide (Reglan) be indicated for gastroesophageal reflux disease (GERD) that worsens at night (HS)?

From the Guidelines

A proton pump inhibitor (PPI) is the preferred initial treatment for GERD that worsens at night, but the addition of metoclopramide (Reglan) may be considered in certain cases, although its use as monotherapy or adjunctive therapy is not strongly supported by recent evidence. The American Gastroenterological Association recommends empirical therapy with antisecretory drugs, such as PPIs, as the initial management for patients with uncomplicated heartburn 1. PPIs have been shown to be more effective than histamine-2 receptor antagonists (HRAs) in treating esophageal GERD syndromes, and there is no evidence to support the use of higher-than-standard doses of PPIs or the addition of a nocturnal dose of an H2RA to twice-daily PPI therapy 1. Some key points to consider when treating GERD that worsens at night include:

• Taking the PPI 30-60 minutes before the evening meal for optimal effect on nighttime symptoms
• Considering non-pharmacological measures such as elevating the head of the bed, avoiding eating within 3 hours of bedtime, and sleeping on the left side when possible
• The potential benefits and risks of adding metoclopramide, which may increase lower esophageal sphincter pressure and accelerate gastric emptying, but its use is not strongly supported by recent evidence 1. It's worth noting that the current consensus is that empirical therapy is appropriate initial management for patients with uncomplicated heartburn, and PPIs are the preferred initial treatment.

From the FDA Drug Label

In patients with gastroesophageal reflux and low LESP (lower esophageal sphincter pressure), single oral doses of metoclopramide produce dose-related increases in LESP. It increases the resting tone of the lower esophageal sphincter Metoclopramide increases the tone and amplitude of gastric (especially antral) contractions, relaxes the pyloric sphincter and the duodenal bulb, and increases peristalsis of the duodenum and jejunum resulting in accelerated gastric emptying and intestinal transit.

A proton pump inhibitor (PPI) and metoclopramide (Reglan) may be indicated for gastroesophageal reflux disease (GERD) that worsens at night, as metoclopramide can help increase the tone of the lower esophageal sphincter and accelerate gastric emptying, which can help reduce symptoms of GERD. However, the use of these medications should be determined on a case-by-case basis, considering the individual patient's needs and medical history 2.

• Key benefits of using metoclopramide for GERD include:
  • Increased tone of the lower esophageal sphincter
  • Accelerated gastric emptying
• Important considerations when using metoclopramide include:
  • Potential side effects, such as extrapyramidal reactions and sedation
  • Individual patient needs and medical history

From the Research

Indications for PPI and Reglan in GERD

• A proton pump inhibitor (PPI) is the first-line drug for gastroesophageal reflux disease (GERD) and is more effective than H2-receptor antagonists (H2RAs) 3.
• PPIs block acid production at nighttime as well as daytime, making them effective for GERD that worsens at night (HS) 3.
• Metoclopramide (Reglan) is sometimes used in combination with H2RAs for GERD, but its effectiveness in combination with PPIs is less clear 4.

Efficacy of Combination Therapy

• One study found that adding an H2-blocker at bedtime to a PPI regimen decreased nocturnal acid breakthrough (NAB) and improved nocturnal gastric acid control in GERD patients 5.
• However, another study found that the addition of metoclopramide to ranitidine did not provide significant benefits over ranitidine alone in patients with poorly responsive symptomatic GERD 4.
• There is limited evidence to support the use of combination therapy with PPIs and metoclopramide for GERD, and more research is needed to determine its efficacy 6.

Treatment Options for GERD

• PPIs are the preferred treatment for GERD due to their potent and prolonged suppression of gastric acid 7.
• The selection of a PPI should be based on factors such as acquisition cost, efficacy, and safety profile 7.
• Metoclopramide may be considered as an adjunctive therapy for GERD, but its use should be individualized and based on patient-specific factors 4.