There is a growing body of pathophysiological evidence that
gastroesophageal reflux disease (
GERD) is caused by disordered motility and not
acid hypersecretion. The key factor in the pathogenesis of
GERD is disordered function of the lower esophageal sphincter. Other factors include delayed gastric emptying and decreased peristalsis in the body of the esophagus. The principal symptoms of
GERD are
heartburn and regurgitation. Studies have demonstrated that up to 50% of patients may have other symptoms of dysmotility including epigastric discomfort or fullness,
nausea and early satiety. The use of a prokinetic agent in such patients seems logical. Given its proven superior efficacy over
domperidone and
metaclopramide in treating
GERD,
cisapride has become the prokinetic
drug of choice for the acute management and maintenance
therapy of
GERD. In the acute management of
GERD,
cisapride is superior to placebo and has the same efficacy as H2 receptor antagonists (H2RAs) in several clinical trials. It is also effective in maintenance
therapy for
GERD. These studies are reviewed.
Cisapride (10 mg qid or 20 mg bid) is effective in the acute treatment of mild to moderate
GERD, particularly in patients with
heartburn associated with other symptoms of dysmotility, and particularly in patients with
heartburn associated with
gastroparesis. Combination
therapy with an H2RA may be considered if symptoms (particularly dysmotility symptoms) persist with H2RA alone. In severe
GERD that is not responsive to conventional doses of a
proton pump inhibitor, cotherapy with
cisapride or increasing the dose of the
proton pump inhibitor are the two therapeutic options to consider.
Cisapride 20 mg at bedtime is effective maintenance
therapy for patients with mild to moderate
GERD.