What medications are appropriate to treat Gastroesophageal Reflux Disease (GERD) in pregnancy?

Treatment of GERD in Pregnancy

For pregnant women with GERD, begin with lifestyle modifications and dietary changes, then escalate to calcium-containing antacids, followed by H2-receptor antagonists (ranitidine preferred), and reserve proton pump inhibitors (lansoprazole preferred) only for severe, intractable symptoms after the first trimester. 1, 2

Step-Up Treatment Algorithm

First-Line: Lifestyle and Dietary Modifications

• Reduce intake of spicy, fatty, acidic, and fried foods 3
• Consume small, frequent meals rather than large portions 3
• Identify and avoid specific food triggers, particularly those with strong odors 3
• These modifications should be attempted first as GERD affects 30-90% of pregnant women, with symptoms typically beginning in the first trimester and progressing throughout pregnancy 3, 1

Second-Line: Antacids and Mucosal Protectants

• Calcium-containing antacids are the preferred first-line medical therapy due to their safety profile and minimal systemic absorption 1, 4
• Magnesium-based antacids can also be used, particularly in patients with preeclampsia 4
• Sucralfate (1g oral tablet, 3 times daily) is an excellent option if symptoms persist with antacids alone, as it has minimal systemic absorption and is considered safe 1, 4
• Alginic acid can be used as an alternative mucosal protectant 4

Third-Line: H2-Receptor Antagonists

• Ranitidine is the preferred H2-receptor antagonist due to its documented efficacy and safety profile throughout pregnancy, including the first trimester 5, 4
• Famotidine is also considered safe, with FDA labeling showing efficacy for GERD symptoms and erosive esophagitis 6
• Nizatidine should be avoided during pregnancy 2
• H2-receptor antagonists should be initiated when symptoms persist despite antacids and sucralfate 1

Fourth-Line: Proton Pump Inhibitors (Reserved for Severe Cases)

• PPIs should be reserved exclusively for women with intractable symptoms or complicated reflux disease that has not responded to the above therapies 5, 2
• Lansoprazole is the preferred PPI based on animal teratogenicity studies and case reports demonstrating safety in human pregnancies 5, 2
• Lansoprazole has demonstrated efficacy in healing erosive esophagitis, with 93-95% healing rates at 6 weeks for the 30mg daily dose 7
• Omeprazole should be avoided during pregnancy 4
• PPIs should not be used during the first trimester except in rare, severe intractable cases, and only after careful consideration of the benefit-harm ratio for both mother and fetus 4, 2

Critical Safety Considerations

Timing and Progression

• Early treatment is essential to prevent progression to hyperemesis gravidarum 3
• The physiologic basis for GERD in pregnancy is primarily hormonal: progesterone causes relaxation of the lower esophageal sphincter, facilitating gastroesophageal reflux 3, 5
• Approximately 25% of pregnant women experience daily heartburn 1

Medications to Avoid

• Metoclopramide and ondansetron should be avoided before 10 weeks of gestation due to possible teratogenic risks 3
• Nizatidine should not be used during pregnancy 2
• Omeprazole is not recommended as the PPI of choice 4

Common Pitfalls

• Do not jump directly to PPIs without attempting the step-up approach, as serious reflux complications during pregnancy are rare and most cases respond to conservative measures 5
• Do not withhold necessary treatment due to pregnancy concerns, as inadequately controlled GERD can significantly impact maternal quality of life and potentially lead to more serious complications 1
• Ensure adequate counseling about the benefit-risk ratio when escalating to systemic therapies, particularly PPIs 2
• Use the least possible amount of systemic medication needed to ameliorate symptoms 2

When to Consider Endoscopy

• Endoscopy can be safely performed during pregnancy with conscious sedation and careful monitoring if symptoms are intractable or atypical 2
• However, routine endoscopy is rarely needed as serious complications are uncommon 5