What is the treatment for gastroesophageal reflux disease (GERD) in patients using Glucagon-like peptide (GLP)-1 analogues?

From the Guidelines

The treatment for GERD in patients using GLP-1 analogues should focus on managing symptoms while continuing weight loss therapy when possible, with first-line treatment including lifestyle modifications and proton pump inhibitors (PPIs) such as omeprazole 20-40mg daily or pantoprazole 40mg daily.

Key Considerations

• Lifestyle modifications are essential and include elevating the head of the bed, avoiding meals 2-3 hours before bedtime, and limiting trigger foods like caffeine, chocolate, and fatty meals.
• For medication management, PPIs are recommended as the most effective option, typically taken 30 minutes before breakfast 1.
• H2 receptor antagonists like famotidine 20mg twice daily can be used as alternatives or add-on therapy.
• Antacids containing aluminum hydroxide or magnesium hydroxide can provide quick symptom relief but only work short-term.
• If symptoms persist despite these measures, the GLP-1 dose may need adjustment or temporary reduction in consultation with the prescribing physician.

Management Approach

• The approach is necessary because GLP-1 analogues slow gastric emptying, which can worsen reflux symptoms, but their benefits for weight management and glycemic control often outweigh these side effects for many patients.
• Severe, persistent symptoms warrant gastroenterology referral for further evaluation.
• A precision approach to escalation of management is suggested for patients with ongoing symptoms despite these measures, driven by factors such as the integrity of the anti-reflux barrier, presence of visceral hypersensitivity and hypervigilance, confirmation of PPI refractory-GERD, symptom profile, body mass index, and esophageal (as well as gastric) motor function 1.

Additional Therapies

• For patients with PPI-refractory GORD symptoms, increasing the dose or switching to another PPI can benefit a subset of patients, and histamine-2 receptor antagonists (H2RA), alginates, in addition to PPI, can improve control of GORD symptoms in some patients 1.
• Baclofen, a GABA agonist, can be useful as an add-on therapy to PPI but is limited by side effects 1.

From the FDA Drug Label

1.7 Treatment of Symptomatic Gastroesophageal Reflux Disease (GERD) Lansoprazole delayed-release capsules are indicated for short-term treatment in adults and pediatric patients 12 to 17 years of age (up to eight weeks) and pediatric patients one to 11 years of age (up to 12 weeks) for the treatment of heartburn and other symptoms associated with GERD

1.4 Treatment of Symptomatic Gastroesophageal Reflux Disease (GERD) Omeprazole delayed-release capsules are indicated for the treatment of heartburn and other symptoms associated with GERD for up to 4 weeks in patients 2 years of age and older.

1. Treatment of GERD. Symptomatic relief commonly occurs within 24 hours after starting therapy with ranitidine 150 mg twice daily.

The treatment for gastroesophageal reflux disease (GERD) in patients using Glucagon-like peptide (GLP)-1 analogues is not directly addressed in the provided drug labels. However, based on the available information, proton pump inhibitors (PPIs) such as lansoprazole and omeprazole, or histamine-2 (H2) blockers like ranitidine, can be used to treat GERD symptoms.

• Lansoprazole is indicated for short-term treatment of GERD in adults and pediatric patients.
• Omeprazole is indicated for the treatment of heartburn and other symptoms associated with GERD for up to 4 weeks.
• Ranitidine provides symptomatic relief of GERD, commonly occurring within 24 hours of starting therapy. It is essential to consult the prescribing information for each medication and consider the individual patient's needs and medical history when selecting a treatment option 2, 3, 4.

From the Research

Treatment of Gastroesophageal Reflux Disease (GERD) in Patients Using GLP-1 Analogues

The treatment of GERD in patients using Glucagon-like peptide (GLP)-1 analogues involves the use of proton pump inhibitors (PPIs) or histamine(2) receptor antagonists (H2RAs) to reduce gastric acid production and alleviate symptoms.

• Proton Pump Inhibitors (PPIs): PPIs are the most potent gastric acid-suppressing agents and are effective in healing duodenal and gastric ulcers, as well as treating GERD 5. Standard daily doses of PPIs are more effective than H2RAs for healing endoscopically proven GERD, and patients should receive a 4 to 8 week course of treatment 5, 6.
• Histamine(2) Receptor Antagonists (H2RAs): H2RAs are less effective than PPIs in relieving heartburn in patients with GERD, but may be used as an alternative treatment option 6, 7.
• Combination Therapy: Combination therapy with PPIs and H2RAs has been evaluated, but there is no conclusive evidence to support the use of combination therapy over PPIs alone in patients with GERD 8.
• GLP-1 Analogues and GERD: Shorter-acting GLP-1 receptor agonists have been associated with an increased risk of developing GERD and its complications, including erosive reflux disease, oesophageal stricture, and Barrett's esophagus 9.

Treatment Recommendations

Based on the available evidence, the following treatment recommendations can be made:

• Patients with GERD using GLP-1 analogues should be treated with PPIs as the first-line therapy to reduce gastric acid production and alleviate symptoms.
• H2RAs may be used as an alternative treatment option in patients who cannot tolerate PPIs or have a contraindication to their use.
• Combination therapy with PPIs and H2RAs is not recommended as a first-line treatment option, but may be considered in patients who do not respond to PPIs alone.
• Patients using shorter-acting GLP-1 receptor agonists should be monitored closely for the development of GERD and its complications, and treated promptly if symptoms occur.