Patients should be advised to lose weight, if it is appropriate, and smokers to quit, as nicotine relaxes the gastro-oesophageal sphincter. Raising the head of the bed by 15-20 cm helps to diminish nocturnal reflux. Patients should be advised to avoid heavy meals and situations predisposing to reflux (such as lying down or prolonged bending within 3 hours of a meal). Drugs that encourage reflux should be avoided if possible, e.g. those with antimuscarinic activity (tricyclic antidepressants), smooth muscle relaxants (nitrates and calcium channel blockers) or theophylline compounds.
Antacids are helpful in controlling mild reflux symptoms when taken regularly after meals with additional doses as needed. Preparations in which an antacid is combined with alginate are particularly useful: the alginate produces a viscous floating gel, which blocks reflux and protectively coats the oesophagus.
Acid suppression. H2-receptor antagonists in conventional peptic ulcer healing doses are useful in the short-term management of mild oesophagitis but are less effective in the longer term and on maintenance treatment only one-third of patients will be in remission. Proton pump inhibitors are currently the most effective drugs. Conventional ulcer healing doses rapidly relieve reflux symptoms and heal oesophagitis in the majority of patients. Sometimes higher doses are needed, particularly for maintenance therapy. Over three-quarters of patients will still be in remission after 12 months' treatment with a proton pump inhibitor.
Pro-kinetic drugs. The antidopaminergic compounds metoclopramide and domperidone can alleviate GORD symptoms by increasing the tone of the gastro-oesophageal sphincter and stimulating gastric
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