I left you hanging last week wondering about the treatment of Gastroesophageal Reflux Disease (GERD). First, a quick review. Recall that acid from the stomach (gastro) is found in the tube that connects the mouth and stomach (esophagus) and goes in a backward direction (reflux).
When I see someone complaining of GERD symptoms in my office I review my patient’s history to try and identify any risk factors for GERD such as decreased tone of the lower esophageal sphincter (LES), loss of normal muscular function of the esophagus, excess production of stomach acid, delayed emptying of the stomach and overeating. Fatty or fried foods, coffee, tea, caffeinated drinks, chocolate and mint are all foods that can cause GERD. Alcohol and cigarette smoking are also risk factors.
Many patients immediately request medication to help control the symptoms rather than try to control the underlying cause(s) of the GERD. Direct-to-consumer advertising has been very effective in selling medications to treat this common problem. If you ask any insurance company what it’s largest drug expense is, it’s often a class of medications called PPIs or Proton Pump Inhibitors (more below).
Simple lifestyle modifications are the foundation of treatment for GERD. Weight reduction is a primary goal. This can usually be accomplished by reducing fat in the diet and stressing the importance of not eating large, fatty meals just before bedtime. Avoiding tight fitting clothing, reducing alcohol consumption, and smoking cessation are also important.
For people who wake up at night with reflux symptoms, I recommend raising the head legs of the bed. The easiest way to do this is to either buy commercial plastic bed risers, cut a 4X4 post into blocks or nail two 2x4’s together. Many people tell me they raise their head by sleeping on a number of pillows, but this bends the body at the waist and can increase pressure in the abdomen, worsening reflux.
Medications may be needed for those who don’t respond to lifestyle modifications. Patients’ response to the treatment of heartburn, the most common symptom of GERD, is much less predictable than treatment for esophagitis that I wrote about last week. Patients may or may not respond to medications and may need to try different medications from various classes to find one that may work for them.
The oldest medications on the market are called histamine antagonists. They block the release of histamine that leads to stomach acid production. The most common ones available include Tagamet ® (cimetidine), and Pepcid ® (famotidine). They are available over the counter and are effective for most people.
The newest class of anti-GERD medications are the Proton Pump Inhibitors or PPIs. These are extremely powerful blockers of acid production. Names that most people recognize (due to very successful marketing) include: Prilosec ®, Protonix ®, Aciphex®, Nexium ®, Zegerid ®, Dexilant ® and Prevacid ®. Why so many? Because they are expensive, making pharmaceutical companies wheelbarrows of money.
These medications are safe and effective for short-term use, but are associated with a slight increased risk of hip fractures in those over age 50, probably due to reducing absorption of calcium in the gut. Many people take PPIs for years thinking they need them because their symptoms return when they stop them. Many of these people suffer from “rebound” reflux. Some call this an “addiction” to PPIs. Once the initial symptoms of GERD are controlled, often they can be controlled with medications that are not as powerful as PPIs. Ask your doctor about ways to try stopping PPIs if you’ve been on them more than a few months.
I get a lot of questions about the “two week warning” found on boxes of GERD medication. It advises people to contact their physician if they have to use the medication longer than two weeks to control their symptoms. This is an important reminder for people to come in and discuss risk factors and develop a game plan to manage their GERD. It’s also important to see a doctor to assess your risk for other more serious complications of GERD that I discussed last week.
The treatment of last resort is surgery. The laparoscopic Nissen fundoplication is the most commonly performed procedure. This involves using minimally invasive endoscopic surgery to take the top portion of the stomach and wrap it around the bottom of the esophagus to tighten it up. It’s very important to see a gastroenterologist and/or surgeon who is very familiar with the procedure to make sure you are a candidate. A newer procedure called the EsophyX TIF allows reconstruction of the lower esophageal sphincter via an endoscope passed through the mouth into the esophagus.