What medications are recommended for managing gastroesophageal reflux disease (GERD) in pregnancy?

Medications for Gastroesophageal Reflux in Pregnancy

Start with lifestyle modifications and calcium-based antacids as first-line therapy, escalating to ranitidine if symptoms persist, and reserving proton pump inhibitors (except omeprazole) only for severe, intractable cases after the first trimester. 1, 2

Step-Up Treatment Algorithm

First-Line: Lifestyle Modifications

• Reduce intake of spicy, fatty, acidic, and fried foods 1
• Consume small, frequent meals rather than large portions 1
• Identify and avoid specific food triggers, particularly those with strong odors 1
• Elevate the head of the bed and avoid lying down immediately after eating 3, 2

Second-Line: Non-Systemic Medications

Calcium-based antacids are the preferred first-line pharmacologic option, offering minimal fetal risk due to lack of systemic absorption 4, 2

Sucralfate (1g orally three times daily) can be introduced if antacids provide inadequate relief, as it is not systemically absorbed and poses minimal risk 4, 3, 2

• Magnesium-based antacids are also acceptable, particularly in patients with preeclampsia 4
• Avoid sodium bicarbonate-containing antacids due to risk of maternal and fetal metabolic alkalosis 3

Third-Line: Histamine-2 Receptor Antagonists

Ranitidine is the preferred H2RA due to documented efficacy and safety profile throughout pregnancy, including the first trimester 4, 5

• Other H2RAs (famotidine, cimetidine) can be used if ranitidine is unavailable 3, 2
• Avoid nizatidine during pregnancy and lactation due to insufficient safety data 6, 3

Fourth-Line: Proton Pump Inhibitors

Reserve PPIs for severe, intractable symptoms or complicated reflux disease after the first trimester 4, 2, 5

• Lansoprazole may be the preferred PPI based on animal teratogenicity studies suggesting the best safety profile 6, 5
• Avoid omeprazole during pregnancy; all other PPIs are FDA category B 3, 2
• PPIs can be considered before anesthesia during labor and delivery for aspiration prophylaxis 6

Critical Safety Considerations

Timing of Medication Initiation

• The first trimester carries the highest teratogenicity risk; use non-systemic agents preferentially during this period 7
• Systemic medications should be reserved for moderate to severe symptoms that fail conservative management 6, 3

Medications to Avoid

• Metoclopramide and ondansetron should be avoided before 10 weeks gestation due to possible risks 1
• Omeprazole should not be used during pregnancy 3, 2
• Nizatidine is contraindicated during pregnancy and lactation 6, 3

Lactation Considerations

During breastfeeding, prioritize medications with minimal systemic absorption such as sucralfate and alginic acid 4

• H2RAs (except nizatidine) are safe during lactation 3
• Most systemic medications are excreted in breast milk; discuss risk-benefit ratio with patients 3

When to Consider Endoscopy

Upper endoscopy can be safely performed during pregnancy with careful monitoring if symptoms are intractable or atypical, though it is rarely needed as serious reflux complications during pregnancy are uncommon 6, 5

• Defer routine endoscopy until after delivery when possible 8
• If required, the second trimester is the preferred timing 8
• Position patient in left lateral position to avoid aortocaval compression 8

Common Pitfalls

• Do not delay treatment: Early intervention prevents progression to more severe symptoms or hyperemesis gravidarum 1
• Do not jump to PPIs: The step-up approach minimizes fetal exposure to systemic medications 3, 2
• Do not assume all antacids are equal: Calcium-based formulations are preferred over sodium bicarbonate 3, 2