The Best Acid Reflux Medication to Use if a Patient has CKD
Proton pump inhibitors or PPIs are very popular medications for patients with gastroesophageal reflux disease and are extremely safe. Many can be purchased over-the-counter (OTC). However, for those with GERD and more advanced chronic kidney disease (CKD), such as those in stages 4 and 5, there has been an association with progression or worsening of kidney function. Some popular proton pump inhibitors include omeprazole (Prilosec), esomeprazole (Nexium), lansoprazole (Prevacid), rabeprazole (AcipHex), and pantoprazole (Protonix).
There can be a risk of switching from a PPI to an alternative reflux medication, such as worsening stomach disease. When prescribed by a gastroenterologist, we need to be careful. If a patient has Barrett’s esophagus, the proton pump inhibitor may need to be continued. In this situation, we like to work with both the stomach provider, the primary provider, and the patient to determine the best strategy. There are times we need to continue the PPI, taking a risk of worsening kidney function.
However, other situations warrant an alternative approach. To protect the kidneys, a switch can be considered. Here, you might try an H2-antagonist, such as famotidine (Pepcid). Famotidine needs to be dosed for a patient’s kidney function. Here is how to dose famotidine or Pepcid according to kidney function:
- If the GFR is greater than 60, then there is no dosage change required.
- If the GFR is between 30-59, and the usual dose is 10 mg twice a day, consider 10 mg once daily or 20 mg every other day.
- If the GFR is between 30-59, and the usual dose is 20 mg once a day, consider 10 mg once daily or 20 mg every other day.
- If the GFR is between 30-59, and the usual dose is 20 mg twice a day, consider 20 mg once daily or 40 mg every other day.
- If the GFR is less than 30, and the usual dose of Famotidine is 10 mg twice a day, consider 10 mg every other day.
- If the GFR is less than 30, and the usual dose is 20 mg once daily, then consider 10 mg of Pepcid every other day.
- If the GFR is less than 30, and the usual dose is 20 mg twice daily, then consider 10 mg once daily or 20 mg every other day.
- If the patient is on hemodialysis three times a week, consider taking after hemodialysis on dialysis days with no supplemental dose required.
- If the patient is on peritoneal dialysis, or kidney replacement therapy through the belly, dose the medication as if the GFR was less than 30 (see above).
The above table might seem confusing at first. Here is my suggestion to transition from a proton pump inhibitor to an H2 blocker such as Pepcid. Find out your GFR from your last set of laboratory values. Next, decide how much H2 blocker you should take. Follow the table above. Increase or decrease the dose of Pepcid to achieve the desired effect of no more reflux.
Let’s transition to other reflux medications with strings attached that chronic kidney disease patient should avoid unless prescribed by a physician. We will start with over-the-counter anti-acids that contain magnesium. Examples of magnesium-based antacids include Mylanta and Maalox. Chronic kidney disease patients should avoid these medications because they put a patient at risk for magnesium toxicity. Amphojel contains aluminum, which can increase in concentration in patients with chronic kidney disease and lead to bone disease. We suggest you avoid aluminum containing medications if possible. In summary, using PPI or H2 blockers in CKD is more complex than it seems. Shared decision making amongst the medical team will allow for a consideration of preventing the progression of CKD using a risk benefit analysis.