Strengthening the Lower Esophageal Sphincter

Strengthening the Lower Esophageal Sphincter
Strengthening the Lower Esophageal Sphincter

The other drugs discussed in this chapter pertain to acid production and acid neutralization, but prokinetics focus on the lower esophageal sphincter (LES). This type of medication is aimed at addressing the root cause of acid reflux instead of simply reducing symptoms.
Prokinetics are available by prescription only and come in liquid, tablet, IV, and subcutaneous injection form. They’re often used in conjunction with other acid reflux and GERD medications, such as H2 receptor antagonists and PPIs. However, the main difference with this class of drug comes down to risks. The potential side effects and complications associated with prokinetics are significantly more serious than the other generally benign acid reflux medications. Due to the potential for serious side effects,

this type of drug will only be prescribed for the most severe GERD cases.
How they work
Prokinetics are a type of drug that helps strengthen the LES by increasing the pressure of the muscles in the LES. If you have acid reflux, your LES is likely the primary culprit behind your discomfort. A weakened LES allows your stomach’s contents to pass back out of the stomach and into the esophagus.
By strengthening your LES, this particular class of drug can dramatically impact your reflux. In some cases, this medication can strengthen your LES to the point where it functions completely normally. This means no more reflux — food and fluid go into the stomach and stay there. Even if this drug doesn’t completely eliminate your reflux, it can have a significant impact on the severity and frequency of your reflux outbursts. A stronger LES will malfunction less frequently, and will allow less stomach content to escape into the esophagus. Not only will your reflux outbursts be less frequent, but they’ll generally be less painful when they do occur.
This type of medication also helps empty the stomach’s contents faster. As you may know, the longer food is in your stomach, the more likely you are to experience a bit of reflux. By simply reducing the amount of time that food stays in your stomach, you reduce the likelihood that you’ll suffer from heartburn or other reflux symptoms.
Because they have a short half-life (the time a drug remains in your bloodstream), prokinetics are usually taken two to four times daily before meals and at bedtime.
What they’re good for
This particular drug type is very good at strengthening muscles and increasing movement in your digestive tract. This drug will help your LES squeeze and enhance the movement of the muscular wall of your stomach and intestines, making food and fluid pass through your

digestive system more quickly. When it comes to treating GERD, most physicians agree that prokinetics taken alone are comparable to H2 blockers, but slightly less effective than PPIs. To maximize their effectiveness, they’re often prescribed in conjunction with acid neutralizers like H2s or PPIs.
As mentioned earlier in this section, they’re also extremely effective at improving esophageal movement. These types of drugs don’t just strengthen the squeeze of the muscles of the LES, they also enhance the squeeze of the muscles lining your esophagus. This makes it easier for you to swallow and for your esophagus to push any food or fluid down into the stomach, which can be helpful when you have acid reflux. Not only is it harder for acid to sneak past the LES, but it’s also easier for your body to push any of your stomach’s contents back down by swallowing.
With stronger movement of the gastrointestinal tract muscles, food and fluids pass through the stomach and intestines more quickly. This faster transport reduces the severity and frequency of GERD symptoms. When used in conjunction with other acid-suppressing or acid-neutralizing drugs, prokinetics can be a useful tool in managing acid reflux.

What they’re not so good for
As mentioned earlier in this section, prokinetics are used only in the most extreme GERD cases due to the high risk level associated with their use. These aren’t drugs you should be on if you only have mild or occasional heartburn or reflux symptoms. If your reflux is primarily associated with specific habits or your diet, this type of medication is unlikely to have any effect on your symptoms.
You shouldn’t use prokinetics in an attempt to relieve or treat your immediate reflux symptoms. Unlike antacids, H2 blockers, or PPIs, prokinetics will have no direct impact on your symptoms. Instead of neutralizing acid or reducing acid production, these drugs simply target the muscles responsible for reflux. This means that taking a dose of

prokinetics will have little immediate effect on your in-the-moment symptoms.
Due to the high-risk side effects associated with long-term use of prokinetics, doctors don’t prescribe them lightly. Modest reflux symptoms won’t get you a prescription for this drug family.

Potential side effects
Prokinetics are one of the higher-risk medications associated with the treatment of acid reflux. Due to the serious medical risks linked with long-term prokinetic use, some physicians will not even consider prokinetics as a treatment option. If they do, it tends to be only in the most severe GERD cases, and it’s often done under strict supervision.
One of the most significant side effects associated with prokinetics is the development of extrapyramidal symptoms, which are closely associated side effects that impact your nervous system. They include
·  Muscle spasms
·  Movements of the tongue and lips
·  Slurred speech

If you find that you’re experiencing any of these symptoms, stop the medication immediately and contact your doctor. Your doctor will likely recommend that you stop any prokinetic use completely. In most cases, especially when caught early, these symptoms will disappear around 24 hours after the last dose of prokinetics.
Doctors rarely prescribe prokinetic medication to patients under 20, because younger patients have a significantly higher risk for these extrapyramidal symptoms.
That’s not the only thing you have to worry about when being treated with prokinetics. On top of diarrhea, nervousness, anxiousness, and agitation, there’s also a
heightened risk of serious cardiac arrhythmias, some of which might be fatal if not treated immediately.
Some studies have also found an increase in pituitary prolactin release, which can lead to impotence, galactorrhea (inappropriate milk release from the breasts, even in men), or menstrual disorders.
More alarming is when patients develop neurological disorders such as
·  Dystonia: A neurological movement disorder where sustained muscle contractions cause twisting and repetitive movements or abnormal postures
·  Tardive dyskinesia: A neurological disorder that leads to frequent, involuntary body movements or spasms
These disorders are extremely serious and something you’ll hopefully never have to deal with. This class of drugs should be avoided in folks who already have a movement disorder, such as people with Parkinson’s disease.
Because of the potential to develop these serious, sometimes incurable, side effects, doctors are always very cautious when prescribing prokinetics.
Be certain that you discuss with your doctor all the possible side effects associated with prokinetics before you begin any form of treatment involving these drugs. Make sure you’re aware of all the warning signs and notify your doctor immediately at the first indication of any of the side effects.

As always, you and your doctor need to weigh the risk factors associated with this medication versus the possible benefits. That said, don’t let the potential side effects scare you away from a treatment that could improve your life, especially if your doctor believes the benefits will be worth the risk.

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