Which specific medications can exacerbate GERD or damage the esophagus

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As mentioned, medications can act in different ways to affect GERD and reflux symptoms (see Table 1). Medications can either affect the nerves that control the LES or the muscles that control the tightness of the LES.

All muscles, including the LES, are controlled by nerves. Muscles of the gut are called smooth muscle and you cannot consciously control them by thinking about it. The nerves transmit signals from the brain to the rest of the body. Nerves that make up what is called the autonomic nervous system automatically control the LES muscle cells. The autonomic nervous system controls functions that are essential for living, such as breathing, contraction of the heart muscle, food digestion, and blood flow throughout the body. For this reason, if medication can affect smooth muscle or the nerves that control the smooth muscle, then it can affect gut function.

The different classes of medications to be aware of include medications for depression (antidepressants), high blood pressure medications (beta-blockers, calcium channel blockers, and nitrates), antinausea

100 QUESTIONS & ANSWERS ABOUT GASTROESOPHAGEAL REFLUX DISEASE (GERD) Table 1 Medications that May Cause Reflux or Heartburn

Medication (generic)

Medication (trade)

Uses I

Amitriptyline

Elavil

Antidepressant medication

Diazepam

Valium

Antianxiety

Diltiazem

Cardizem, Cartia, Tiazac

Calcium channel blocker—High blood pressure

Doxepin

Sinequan

Antidepressant medication

Felodipine

Plendil

Calcium channel blocker—High blood pressure

Imipr

Tofranil

Imipr

Tofranil

Antidepressant medication

Isosorbide nitrate Imdur, Nitrodur Nitrates—High blood pressure or angina

Labetalol

n/a

Beta-Blocker—High blood pressure

Levodopa

Sinemet

Anti-Parkinsons

Nifedipine

Adalat, Procardia

Calcium channel blocker - High blood pressure

Nortriptyline

Aventyl, Pamelor

Antidepressant medication

Progestin n/a Birth control or abnormal menstrual bleeding

Theophylline Theolair, Uniphyl AntiAsthma

Metoprolol Toprol Beta blocker—High blood pressure medications (anticholinergics), pain medications (narcotics), hormones, sedatives, and some asthma medications (theophylline).

The anticholinergic medications, such as antinausea medications, control the autonomic nerves responsible for digestion. These medications can decrease the nerve output to the muscles of the LES, thereby causing the muscles to relax and worsening the symptoms of GERD. Anticholingeric medications also slow stomach emptying, giving reflux more time to occur. Examples of commonly prescribed anticholinergic medications used for nausea are prochlorperazine (Compazine), promethazine (Phenergan), and scopolamine.

Medications for high blood pressure called calcium-channel blockers or beta-blockers can, on the other hand, directly affect the tightness of the muscles of the LES. These medications affect certain muscles in the blood vessels and relax them to lower blood pressure. Because they relax smooth muscle, they delay stomach emptying. Examples of these are nifedipine (Procardia), diltiazem (Cartia and Cardizem), verapamil (Calan), inderal (Propanolol), and nadolol (Corgard).

Medications for asthma can also affect the LES and impair its ability to contract. An example is theo-phylline, which relaxes smooth muscle. Smooth muscle lines the airways of the lungs. When these muscles go into spasms, asthma occurs. Asthma medications work by relaxing and opening the airways to make breathing easier. However, these muscles are similar to the muscles controlling the LES. Therefore, along with relaxing the muscles in the lungs, asthma medications can also relax the muscle in the LES. Asthma medications that can exacerbate reflux include theophylline (Uniphyl) and some inhalers such as albuterol.

Through similar mechanisms, other medications, including pain medications, sedating medications, and even antidepressants, can also loosen the LES and cause reflux symptoms to worsen. Many medications used for depression have anticholinergic effects (similar to medications for nausea); examples are amitriptyline (Elavil), desipramine, and imipramine. Narcotics used for severe pain such as morphine, fentanyl, long-acting narcotics oxycodone (Oxycontin), and morphine sulphate (MS Contin) all delay gastric emptying. Female hormones also relax the LES; these include most estrogen-containing medications and are commonly used by women going through menopause.

Finally, as mentioned previously, most medications used for thinning of the bones or osteoporosis are direct irritants and can damage the esophagus. This class of drugs is called bisphosphonates and limits the body's ability to metabolize bone. This limits breakdown of bones and keeps them strong. These medications should not be taken by people who have difficulty swallowing because the pills can lodge in the esophagus, causing damage. An example of bisphosphonate medication is alendronate (Fosamax). Several other medications are also acidic or corrosive and damage the esophagus on contact. These are potassium pills, iron supplements, quinidine (a heart medication) and antibiotics such as tetracycline and doxycycline.

All of these medications are very commonly used and have the potential side effect of increasing GERD or directly damaging the esophagus.

Mucosa the lining of the gut. Each gut organ has a special mucosa that can be identified under the microscope. The mucosa is like the "skin" lining the gut.

Some medications affect the mucosa so much that the body cannot produce cells fast enough and certain areas become exposed, allowing damage from acid or other digestive juices.

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