From the Guidelines
The treatment of GERD during pregnancy should begin with lifestyle modifications, including dietary changes and avoidance of trigger foods, before considering medications, as recommended by the American College of Obstetricians and Gynecologists (ACOG) 1. The initial steps in managing GERD symptoms in pregnancy involve reducing spicy, fatty, acidic, and fried foods, which can help to reduce heartburn. Eating small, frequent, and bland meals, such as the BRAT (bananas, rice, applesauce, and toast) diet, and high-protein and low-fat meals can also be helpful. Some key lifestyle modifications include:
- Eating smaller, more frequent meals
- Avoiding lying down for 2-3 hours after eating
- Elevating the head of the bed by 6-8 inches
- Avoiding trigger foods like spicy, fatty, or acidic items, caffeine, and chocolate If these measures are insufficient, antacids containing calcium carbonate or aluminum hydroxide (like Tums or Maalox) are considered first-line medication therapy and are safe during pregnancy 1. For persistent symptoms, sucralfate (1g four times daily) can be used. If further treatment is needed, H2-receptor antagonists like ranitidine (150mg twice daily) are generally considered safe. For severe, refractory GERD, proton pump inhibitors such as omeprazole (20-40mg daily) may be used, particularly in the second and third trimesters, as they have been shown to be effective in reducing symptoms while minimizing risks to the developing fetus 1. These medications work by either neutralizing stomach acid (antacids), creating a protective barrier (sucralfate), or reducing acid production (H2-blockers and PPIs). Treatment should follow a step-up approach, starting with the safest options and escalating only as needed, while always balancing symptom relief against potential risks to the developing fetus.
From the FDA Drug Label
14.3 Symptomatic Gastroesophageal Reflux Disease (GERD) Orally-administered Famotidine was compared to placebo in a U. S. trial that enrolled patients with symptoms of GERD and without endoscopic evidence of esophageal erosion or ulceration.
- Treatment of GERD. Symptomatic relief commonly occurs within 24 hours after starting therapy with ranitidine 150 mg twice daily.
The treatment of GERD in pregnancy is not directly addressed in the provided drug labels. However, based on the available information, Famotidine and Ranitidine can be used to treat GERD.
- Famotidine 20 mg twice daily has been shown to improve symptomatic GERD.
- Ranitidine 150 mg twice daily can provide symptomatic relief of GERD within 24 hours. It is essential to consult the FDA drug label for the most up-to-date information and to consult a healthcare professional for guidance on treating GERD in pregnancy 2 3.
From the Research
Treatment Approach
- The treatment of GERD in pregnancy should follow a step-up approach, starting with lifestyle modifications and dietary changes 4, 5, 6, 7, 8.
- If symptoms persist, antacids or sucralfate are considered the first-line medical therapy 4, 5, 6, 7, 8.
Medication Options
- Antacids, specifically calcium-containing antacids, are the preferred choice 5.
- Sucralfate can be introduced if symptoms persist with antacids 5, 6, 7.
- Histamine-2 receptor antagonists (H2RAs), such as ranitidine, can be used if symptoms persist 4, 5, 6, 7.
- Proton-pump inhibitors (PPIs) are reserved for women with intractable symptoms or complicated reflux disease 4, 5, 6, 7, 8.
- Lansoprazole may be the preferred PPI due to its safety profile in animals and human pregnancies 4, 7.
Safety Considerations
- Medications used to treat GERD during pregnancy should be used with caution, as safety data are based on animal studies, human case reports, and cohort studies 7.
- The use of the least possible amount of systemic drug needed to ameliorate symptoms is recommended 7.
- Patients who have become pregnant while using these drugs can be reassured, but prescription should be delayed until after the first trimester whenever possible 8.