Mechanism of Action and Clinical Use of PPIs and Prokinetic Agents for the Treatment of GERD and Nursing Implications.

Mechanism of Action and Clinical Use of PPIs and Prokinetic Agents for the Treatment of GERD and Nursing Implications.

Gastroesophageal reflux disease (GERD) is arguably the most common disease encountered by the gastroenterologist. It is equally likely that the primary care providers will find that complaints related to reflux disease constitute a large proportion of their practice. Gastroesophageal reflux is the backflow of gastric and duodenal contents into the esophagus. The reflux is caused by an incompetent lower esophageal sphincter, pyloric stenosis, or motility disorder (Katz, Gerson, & Vela, 2013).

Approximately 80% of patients have a recurrent but nonprogressive form of GERD that is controlled with medications. Treatment of gastroesophageal reflux disease (GERD) involves a stepwise approach. The goals are to control symptoms, to heal esophagitis, and to prevent recurrent esophagitis or other complications. The treatment is based on lifestyle modification and control of gastric acid secretion through medical therapy with PPIs and prokinetic agent or surgical treatment in extreme cases when medical management is unsuccessful (Arora & Castell, 2011).

Mechanism of Action of PPI and Prokinetic Agent

Proton pump inhibitors (PPIs) act directly on the secretory surface of the gastric parietal cells at the final step of acid production to decrease acid levels in the stomach. These agents inhibit the hydrogen-potassium-ATPase gastric enzyme system, which catalyzes the final step. PPIs are absorbed rapidly when given orally. Their antisecretory effects last up to 72 hours. On the other side, prokinetic GI drug (metoclopramide) increases the motion through the GI tract. Metoclopramide is a cholinergic drug that stimulates motility of the upper GI without increasing gastric, biliary, or pancreatic secretions. It also increases the tone of gastric contractions, relaxes the pyloric sphincter, and increases peristalsis of the duodenum and jejunum. The result is increased gastric emptying time. The exact mechanism of action is unknown, but metoclopramide appears to sensitize the GI smooth muscle to acetylcholine (McCuistion & Gutierrez, 2007).

Clinical Use of PPIs and Metoclopramide for the Treatment of GERD

Proton pump inhibitors are used in the treatment of GERD, esophagitis, peptic and duodenal ulcers, and other hypersecretory syndromes. Metoclopramide is indicated in short-term treatment (4-12 weeks) of adults with GERD who fail to respond to conventional treatment and also in patients with paralytic ileus (McCuistion & Gutierrez, 2007).

PPIs are the most powerful medications available for treating GERD. Available PPIs include omeprazole (Prilosec), lansoprazole (Prevacid), rabeprazole (Aciphex), pantoprazole (Protonix), and esomeprazole (Nexium). An 8-week course of PPIs is the therapy of choice for symptom relief and healing of erosive esophagitis. There are no major differences in efficacy between the different PPIs. Proton pump inhibitor therapy should be initiated at once a day dosing, before the first meal of the day. For patients with partial response to once daily therapy, tailored therapy with adjustment of dose timing and/or twice daily dosing should be considered in patients with night-time symptoms, variable schedules, and/or sleep disturbance. Non-responders to PPI should be referred for evaluation. In patients with partial response to PPI therapy, increasing the dose to twice daily therapy or switching to a different PPI may provide additional symptom relief. Maintenance PPI therapy should be administered for GERD patients who continue to have symptoms after PPI is discontinued and in patients with complications including erosive esophagitis and Barrett’s esophagus. For patients who require long-term PPI therapy, it should be administered in the lowest effective dose, including on demand or intermittent therapy.

Because GERD is primarily a motility disorder, prokinetic therapy with metoclopramide in addition to PPI therapy is an option often considered for GERD patients. Because drugs work in different ways, combinations of medications may help control symptoms (Katz, Gerson, & Vela, 2013).

Nursing Implications during the Treatment and Care of the Patient

· When taking care of patients with GERD, the nurse should instruct them to avoid factors that decrease lower esophageal sphincter pressure or cause esophageal irritation such as peppermint, chocolate, coffee, fried foods, carbonated and alcoholic beverages, and cigarette smoking.

· Instruct the patient to eat a low-fat, high-fiber diet, and to avoid eating and drinking two hours before bedtime, and also evade wearing tight clothes; in addition, elevate the head of the bed on 6-to 8-inch blocks (Silvestri, 2014).

When administering PPIs, the nurse should:

· Instruct the patient to avoid opening, chewing, or crushing capsules. These medications should be swallowed whole for therapeutic effect.

· Teach the patient to take a proton pump inhibitors 30 minutes before meals to ensure drug efficacy.

· Instruct the patient to return for follow- up medical treatment when the symptoms are unresolved after 4 to 8 weeks of therapy (McCuistion & Gutierrez, 2007).

When administering prokinetic GI agents, the nurse should:

· Administer the oral dose 30 minutes before meals and at bed time.

· Monitor for tardive dyskinesia symptoms, including involuntary movements of tongue, mouth or jaw, face or extremities. This adverse effect is potentially irreversible. Metoclopramide may mask symptoms, which may make recognition of tardive dyskinesia more difficult. When symptoms occur, withhold the medication and notify the health care provider inmediately.

· Encourage the patients who are taking prokinetics to have adequate fluid intake.

· Advice the patient to avoid hazardous tasks, for example, driving for a few hours after taking metoclopramide because the agent may cause sedation and impair mental and physical abilities.

· Counsel the patient to avoid alcohol and other central nervous system depressants, such as sedatives, hypnotics, narcotics, all of which may increase sedation (McCuistion & Gutierrez, 2007).


Arora, A. S., & Castell, D. O. (2011). Medical therapy for gastroesophageal reflux disease. Mayo Clinic Proceedings, 76(1), 102-6. Retrieved from

Katz, P. O., Gerson, L. B., & Vela, M. F. (2013). Guidelines for the diagnosis and management of gastroesophageal reflux disease. The American Journal of Gastroenterology, 108(3), 308-328.

McCuistion, L.E., & Gutierrez, K.J. (2007). Nursing survival guide. In Pharmacology: Drug used to treat gastrointestinal system disorders (2nd ed., pp. 404-437). St. Louis, MO: Elsevier/Saunders.
Silvestri, L.A. (2014). Saunders comprehensive review for the NCLEX-RN® examination. In Gastrointestinal medications (6th ed., p. 714). St. Louis, MO: Elsevier/Saunders.


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