the present invention relates to a novel combination of methods for the treatment of gastroesophageal reflux disease . the combined method on the one hand comprises inhibiting the normal binding of the hormone gastrin 17 to its physiological receptor by actively immunizing the patient against his or her own gastrin 17 hormone . alternatively or additionally , the hormone gastrin 34 can be neutralized by active or passive immunization with g34 or c - terminal g17 peptide fragment . on the other hand , the method provides inhibition of production of gastric acid either by proton pump inhibition or h 2 receptor blockage . the invention provides a novel immunological method for the treatment of gastroesophageal reflux disease using a peptide immunogen which raises sufficient gastrin 17 or gastrin 34 antibody levels in a patient so as to affect the binding of the gastrin 17 or gastrin 34 to its physiological receptors in the patient and raise the ph of the stomach . gastric acid secretion in the stomach can thus be controlled . the ph of the stomach contents is simultaneously raised to a sufficient ph level , e . g ., greater than ph 3 for a prolonged and sufficient period of time to alleviate the gerd symptoms and heal the acid - induced esophagitis . according to the invention , anti - g17 antibodies are induced in the patient by active immunization with peptide immunogens which comprise a g17 immunogen conjugated to an immunogenic carrier . the antibodies raised in the patient by the immunogens selectively and specifically bind gastrin hormone gi 7 or g34 or both , and neutralize and inhibit separately or together the normal binding of gastrin g17 or g34 or both to its receptors in the parietal cells , thereby controlling acid output in the stomach and preventing gastric acid damage of the esophageal mucosa during regurgitation . a preferred embodiment of the inventive method provides a single administration of an active gastrin 17 or g34 immunogen , which has several advantages over the standard therapies of the art for treating gerd in that problems with patient compliance and undesirable side effects as a result of the therapy are eliminated . other advantages of using the immunological methods for the treatment of gerd include the use of a limited number of administrations . a single primary administration with appropriately spaced boosters may last for approximately 6 months to a year . another advantage is that , in a combination therapy with h 2 agonists or proton pump inhibitors , effective anti - gastrin 17 antibody titers can be maintained by occasional booster shots while the gastric acid inhibitor dosing is reduced or discontinued . another advantage of this invention is that the maintenance of antigastrin antibody titers reduces or prevents excessive levels of gastrin in hypogastrinemia which would otherwise result from administration of a proton pump inhibitor or h 2 blocker . a booster shot of the immunological composition prolongs anti - gastrin 17 immunity and gastric acid suppression . still another advantage of this method is that the immunization allows a sufficient time for the esophagitis to completely heal . additionally , no surgery is required . yet another advantage is that combination therapy is more useful for treating severe cases of gerd , without causing undesirable side effects , since excess serum gastrin 17 peptides are physiologically neutralized . in patients where the gerd condition is alleviated , discontinuation of the booster dose may result in resumption of normal gastrin levels . according to the method of the invention , an immunogen is prepared using peptides or chemical structures that mimic the amino terminal end of gastrin 17 or of gastrin 34 . the immunogens and immunogenic compositions of the invention are those described in u . s . pat . nos . 5 , 023 , 077 , 5 , 469 , 494 and 5 , 609 , 870 . the disclosures of these issued patents are hereby incorporated by reference in their entirety . u . s . pat . nos . 5 , 023 , 077 , 5 , 469 , 494 , and 5 , 609 , 870 disclose compositions containing anti - gastrin 17 immunogens as well as anti - gastrin 34 immunogens and methods of using these compositions for the treatment of gastric and duodenal ulcers and gastrin responsive cancers . in the present invention , effective dosages ranging from 0 . 1 mg to 5 g of the immunogenic composition are administered for the treatment of gerd combined with 10 - 80 mg daily dose of omeprazole . an effective dosage of the immunogenic composition is capable of eliciting an immune response in a patient and inducing antibody titer against human gastrin 17 within 1 - 3 months after immunization . effective treatment of gerd according to this method results in maintenance of the ph of the stomach contents above ph 3 or 4 , and for a more prolonged period of time than with h 2 antagonist therapy . maintenance of the stomach ph above 3 or 4 is essential in the treatment of gerd , since refluxate material having a ph below 2 . 0 causes esophagitis by protein denaturation and cell damage , and ph values below 2 . 5 triggers painful episodes in a patient . when the ph is maintained above 2 . 5 , pain perception is almost nonexistent ( smith , et al gastroenterology 96 : 683 - 689 , 1989 ) and damage to the esophageal wall is minimized . the immunogens and immunogenic compositions of the invention typically induce specific antibody responses after a single administration . however , it may take several weeks or months for antibody titers to rise to the desired levels effective for the treatment of gerd . combination therapy with a histamine h 2 antagonist , such as ranitidine , cimetidine , fomatidine and nazatidine , or a proton pump inhibitor , such as omeprazole or lansoprazole , is designed so that a gerd patient is immunized with an immunogenic composition of the invention , and administration of h 2 antagonist is provided on a daily basis , at least once a day for the first 2 - 12 weeks of treatment or until the desired serum level of anti - gastrin 17 antibodies is obtained . desired anti - gastrin 17 serum levels range from 10 to 300 pmole / ml . once the desired serum levels of anti - gastrin 17 antibody titer are obtained as measured by elisa or ria , the non - immunological gastric acid inhibiting drug portion of the combination therapy may be reduced or discontinued . in the following examples , the anti g17 immunogenic composition , 150 mg ranitidine and 60 mg omeprazole were administered to pigs and the resulting changes in the ph of the stomach contents before and after treatment were measured . specifically , following the stomach ph measurements of the untreated control state of each pig , the stomach ph of the same pigs was measured after the animals were treated with either ranitidine , or composition of human gastrin 17 ( 1 - 9 )- h ( g17 ) ser9 - diphtheria toxoid ( gastrimmune ), or omeprazole administered individually and at different times in each of four animals ( pigs ). gastrin neutralization was achieved by using the immunological composition gastrimmune which is composed of the amino terminal domain of gastrin - 17 linked , via an amino acid or peptide spacer to diphtheria toxoid which acts as the immunogenic carries . the antibodies raised by virtue of the design of the immunogen , cross - reacted with both amidated and glycine - extended gastrin - 17 , two known proliferative forms of gastrin . serum antibody titers rose within 2 weeks of the initial immunization to levels with an antigen binding capacity of & gt ; 10 − 9 m . the presence of anti - gastrin antibodies within the serum of gastrimmune - immunized mice was confirmed by using an elisa . as expected , no bound gastrin levels were detected in animals immunized with control immunogen . as can be seen in fig1 and fig2 the ph of the stomach contents remained above ph 3 or 4 in anti - gastrin 17 immunized pigs for a longer period of time than in the pigs treated with ranitidine . in omeprazole treated pigs the stomach ph was maintained above ph 3 or 4 for a longer period of time than pigs which were treated with ranitidine and anti - g17 immunized pigs . in addition , fig3 shows the median ph exhibited by the stomach contents of control pigs when compared to ranitidine , anti - gi 7 immunization and omeprazole treatment . the data shows that the stomach ph is maintained at higher levels in pigs than those treated with ranitidine or anti - g17 immunization therapy . anti - g17 immunized pigs had a median ph higher than ranitidine treated pigs . treatment of the pigs with ranitidine was less effective in preventing acid output from the stomach . omeprazole treatment highly inhibited acid output . a single administration of anti - gastrin 17 immunization inhibited stomach acid output at a level of effectiveness between ranitidine and omeprazole , and sufficient to reduce the stomach acid output levels and increase the stomach ph for the effective treatment of gerd . a treatment which combines the gastric acid secretion with proton pump inhibitors or h 2 histamine blockers with the novel immunization by e . g . gastrimmune can thus result in maintaining favorably raised ph in the stomach . furthermore , the treatment with occasional , effective boosters of the antigastrin immunogenic composition can eventually , possibly within a few months , obviate any additional treatment with the anti - acid secretion drugs , such as e . g . omeprazole or ranitidine . one of the possible advantages of the administration of a proton pump inhibitor or h 2 blocker after immunization with an antigastrin immunogen , as described , resides in the use of lower amounts of the proton pump inhibitor or h 2 blocker for effective lowering of gastrin acid secretion or raising of stomach ph to about 3 - 4 . the human patient suffering from gerd is immunized with 200 μg - 400 μg of primary i . v . inoculation of g17 ( 1 - 9 ) ser dt immunogen composition . after 2 weeks a booster of 100 - 200 μg of the g17 ( 1 - 9 ) ser : dt composition is similarly administered . when the anti - g17 titer has reached a level of about 10 - 300 pmole / ml sufficient to lower the serum gastrin level to near normal with a concomitant lowering of gastric acid secretion , about 10 - 20 mg oral omeprazole preparation is administered daily to further reduce or stabilize the gastric secretion at a level which essentially eliminates or substantially ameliorates the gerd symptoms . immunogens capable of inducing specific immune responses to either g17 or to g34 were prepared by standard solid state synthesis methods . each peptide was characterized as to amino acid content and purity . each of these peptides were conjugated to amino groups present on a carrier such as diphtheria toxoid (“ dt ”) via the terminal peptide cysteine residue utilizing heterobifunctional linking agents containing a succinimidyl ester at one end and maleimide at the other end of the linking agent . to accomplish the linkage between any of peptides 1 - 6 above and the carrier , the dry peptide was dissolved in 0 . 1 m sodium phosphate buffer , ph 8 . 0 , with a thirty molar excess of dithiothreitol (“ dtt ”). the solution was stirred under a water saturated nitrogen gas atmosphere for four hours . the peptide containing reduced cysteine was separated from the other components by chromatography over a g10 sephadex column equilibrated with 0 . 2 m acetic acid . the peptide was lyophilized and stored under vacuum until used . the carrier was activated by treatment with the heterobifunctional linking agent , e . g ., epsilon - maleimidocaproic acid n - hydroxysuccinimide ester , (“ emcs ”), in proportions sufficient to achieve activation of approximately 25 free amino groups per 10 5 molecular weight of carrier . in the specific instance of diphtheria toxoid , this amounted to the addition of 6 . 18 mg of emcs ( purity 75 %) to each 20 mg of diphtheria toxoid . activation of diphtheria toxoid was accomplished by dissolving each 20 mg aliquot of diphtheria toxoid in 1 ml of 0 . 2 m sodium phosphate buffer , ph 6 . 45 . aliquots of 6 . 18 mg emcs were dissolved into 0 . 2 ml of dimethyl formamide (“ dmf ”). under darkened conditions , the emcs was added dropwise in 50 microliter (“ ul ”) amounts to the dt with stirring . after 2 hours of incubation in darkness , the mixture was chromatographed on a g50 sephadex column equilibrated with 0 . 1 m sodium citrate buffer , ph 6 . 0 , containing 0 . 1 mm edta . fractions containing the emcs activated diphtheria toxoid were concentrated over a pm 10 ultrafiltration membrane under conditions of darkness . the protein content of the concentrate was determined by either the lowry or bradford methods . the emcs content of the carrier was determined by incubation of the activated carrier with cysteine - hci followed by reaction with 10 mm of elman &# 39 ; s reagent 5 , 5 ′ dithio - bis ( 2 - nitrobenzoic acid ) 10 mm . the optical density difference between a blank tube containing cysteine - hcl and the sample tube containing cysteine - hcl and carrier was translated into emcs group content by using the molar extinction coefficient of 13 . 6 × 10 3 for 5 - thio - 2 - nitro benzoic acid at 412 nm . the reduced cysteine content (— sh ) of the peptide was also determined utilizing elman &# 39 ; s reagent . approximately 1 mg of peptide was dissolved in 1 ml of nitrogen gas saturated water and a 0 . 1 ml aliquot of this solution was reacted with elman &# 39 ; s reagent . utilizing the molar extinction coefficient of 5 - thio - 2 - nitro - benzoic acid ( 13 . 6 × 10 3 ), the free cysteine — sh was calculated . an amount of peptide containing sufficient free — sh to react with each of the 25 emcs activated amino groups on the carrier was dissolved in 0 . 1 m sodium citrate buffer , ph 6 . 0 , containing 0 . 1 mm edta , and added dropwise to the emcs activated carrier under darkened conditions . after all the peptide solution had been added to the carrier , the mixture was incubated overnight in the dark under a water saturated nitrogen gas atmosphere . the conjugate of the peptide linked to the carrier via emcs is separated from other components of the mixture by chromatography over a g50 sephadex column equilibrated with 0 . 2 m ammonium bicarbonate . the conjugate eluted in the column void volume is lyophilized and stored desiccated at 20 ° c . until used . the conjugate may be characterized as to peptide content by a number of methods known to those skilled in the art including weight gain , amino acid analysis , etc . conjugates of these peptides and diphtheria toxoid produced by these methods were determined to have 20 - 25 moles of peptide per 10 5 mw of carrier and all were considered suitable as immunogens for immunization of test animals . peptide hg17 ( 1 - 9 )- ser9 was prepared by standard solid state synthesis methods . that peptide contains an amino terminal immunomimic of hg17 followed by a carboxy terminal spacer . this peptide comprises a 9 amino acid immunomimic of hg17 ( pglu - gly - pro - trp - leu - glu - glu - glu - glu -) [ seq id no : 7 ] followed by the “ ser ” spacer (- ser - ser - pro - pro - pro - pro - cys ) [ seq id no : 8 ] attached to amino acid number 9 of the hg17 immunomimic . the peptide was conjugated to amino groups present on the diphtheria toxoid (“ dt ”) immunogenic carder via the terminal peptide cysteine residue utilizing heterobifunctional linking agents containing a succinimidyl ester at one end and maleimide at the other end of the linking agent essentially as described in example 4 . the immunogenic constructs of this invention include an aminoterminal ( 1 - 9 ) g17 peptide or an aminoterminal ( 1 - 6 ) g34 peptide conjugated via a peptide spacer to an immunogenic carrier . the preferred g17 sequence is pyro - glu - gly - pro - trp - leu - glu - glu - glu - glu [ seq id no : 7 ] and the preferred g34 sequence is pglu - leu - gly - pro - gln - gly - arg - pro - pro - pro - pro - cys [ seq id no : 5 ]. the preferred spacer in both constructs is a ser - peptide ( ser - ser - pro - pro - pro - pro - cys ) [ seq id no : 8 ]. the preferred immunogenic carrier is diphtheria toxoid , tetanus toxoid , keylimpet hemocyanin , and bovine serum albumin ( bsa ). the gastrin immunogen is defined as a conjugate of the pglu - gly - pro - trp - leu - glu - glu - glu - glu [ seq id no : 7 ] peptide sequence , with an amino acid spacer linked to an immunogenic carrier . the preferred gastrin immunogen is defined as a conjugate of the ( 1 - 9 ) amino terminal ( pglu - gly - pro - trp - leu - glu - glu - glu - glu ) [ seq id no : 7 ] peptide which is linked by peptide spacer to diphtheria toxoid . numerous modifications and variations of the present invention are included in the above - identified specification and are expected to be obvious to one of skill in the art . such modifications and alterations to the compositions and processes of the present invention are believed to be encompassed in the scope of the claims appended hereto .
a method for the treatment of gastroesophageal reflux disease comprising a combination of active immunization with an anti - gastrin immunogenic composition with an antagonist which blocks or inhibits the gastric acid pump activity ; or alternatively administering purified anti - gastrin antibodies with a h 2 antagonist or proton pump inhibitor of the gastric acid producing enzyme system .