June 2016 - Non-Medicated Life
Choosing the Appropriate Treatment for GERD
By Dr. Paul E. Lemanski, MD, MS, FACP
Editor’s Note: This is the 71st in a series on optimal diet and lifestyle to help prevent and treat disease. Any planned change in diet, exercise or treatment should be discussed with and approved by your personal physician before implementation. The help of a registered dietitian in the implementation of dietary changes is strongly recommended.
Medicines are a mainstay of American life and the healthcare system, not only because they are perceived to work by the individuals taking them, but also because their benefit may be shown by the objective assessment of scientific study. Clinical research trials have shown that some of the medicines of Western science may reduce the risk of heart attacks, strokes and cardiovascular death, while others may reduce certain types of cancer.
In the first 70 installments of the Non-Medicated Life, informed diet and lifestyle have been shown to accomplish naturally for the majority of individuals, many, if not most of the benefits of medications in the prevention and treatment of chronic medical conditions. When implemented by an individual, informed diet and lifestyle as a medical intervention may accomplish such benefits at lower risk for side effects, and may reduce the number and amount of medications – and may allow actual discontinuation of medication.
The benefits of a lifestyle approach over a drug approach are exemplified in the treatment of gastro-esophageal reflux disease (GERD) with proton pump inhibitors (PPIs), which while widely used have recently been shown to be associated with serious side effects with long term use.
GERD is a very common disorder in which acid moves from the stomach toward the mouth through the esophagus, the muscular tube which connects the two. Normally, such a movement of acid is prevented, in part, by a tight ring of muscle, called a sphincter at the base of the esophagus. This muscular ring temporarily relaxes to allow food moving down the esophagus to enter the stomach, only to quickly retighten. There are conditions, however, when this normal process is compromised.
If the sphincter is relaxed, then acid from the stomach may reflux back into the esophagus causing symptoms of heartburn, difficulty and pain on swallowing, and even chronic cough. Ingested substances which may relax the sphincter include caffeine, alcohol, and chocolate. Additionally, increased pressure in the abdomen may force acid retrograde through a normally tightened sphincter, or through a sphincter partially relaxed by even modest consumption of such substances. Increased abdominal pressure occurs with increased body weight, and especially with obesity, and the use of tight garments and overly restrictive belts. Further, increased stomach acid will also increase the probability that some of the increased volume of acid will reflux back into the esophagus. Finally, associated conditions such as hiatal hernia may exacerbate reflux.
PPIs (e.g., esomeprazole, lansoprazole, omeprazole, pantoprazole and rabeprazole) are drugs which work to reduce GERD by inhibiting an enzyme in the stomach wall central to acid production. Indeed, they work effectively to treat any condition related to stomach acid, including the healing of gastro-duodenal ulcers, the prevention of gastro-duodenal ulcers associated with nonsteroidal anti-inflammatory drugs, the eradication of the ulcer producing bacterium H. pylori, and the healing of inflammation and ulcers of the esophagus. They are especially useful in the treatment of a pre-malignant condition of the esophagus, called Barrett’s esophagus, in which uncontrolled GERD may actually lead to cancer of the esophagus.
Unfortunately, PPIs, as with most medications, have side effects. Moreover, the side effects are increased by the typical long-term use of the drugs. Recently, three main concerns with the long term use of PPIs have received attention: possible infections, disturbances of blood minerals such as calcium and magnesium, and metabolic bone disease.
Gastric acid is normally beneficial in that it helps to kill bad bacteria that are ingested with food. PPI use has been associated with diarrhea caused by the bacteria clostridia difficile (c. diff), even in those not taking antibiotics, which normally predispose to its growth in the bowels. As a consequence, the FDA has issued a safety alert to consider c. diff associated disease in those using PPIs who have persistent unexplained diarrhea. FDA is also recommending practitioners prescribe the lowest dose and the shortest duration of therapy for conditions treated with PPIs. Additionally, the decrease in gastric acid in the stomach from PPI use may allow bad bacteria to colonize the upper gastrointestinal tract, and may increase the risk of pneumonia – an issue of potential concern for those with chronic obstructive pulmonary disease.
Gastric acid is also beneficial in the absorption of minerals, including magnesium and calcium. The significant reduction of stomach acid occurring with PPIs has been associated with reduced absorption of these minerals when used long term – generally more than one year. The FDA has suggested that practitioners consider measuring magnesium levels prior to starting PPIs and periodically in those expected to remain on a drug long-term. Low magnesium may increase the risk for heart arrhythmias. Because of possible reduced calcium absorption and possible adverse impact on bone density, the FDA is also suggesting the lowest dose and shortest course of PPI use that is appropriate.
Given these concerns, a non-medicated approach to GERD should be implemented both to decrease the dose used, and to possibly discontinue use when possible and appropriate. Patients should always first discuss the risk and benefits of decreasing and discontinuing PPI treatment with their primary care physician before implementing. Conditions such as Barrett’s esophagus, which may increase the risk of cancer of the esophagus, generally, would preclude discontinuation.
The non-medicated approach to GERD includes a reduction of substances which relax the lower esophageal sphincter, a reduction in substances that increase stomach acid, and a reduction of abdominal pressure. Reducing and/or eliminating caffeine consumption by switching to decaffeinated coffee and tea is generally helpful. So is reducing and/or eliminating alcohol consumption. Both caffeine and alcohol both relax the sphincter and increase acid produced by the stomach. Chocolate consumption should be minimized or eliminated if possible. For those who use tobacco a reduction in cigarette use, e-cigarettes, cigars, pipe tobacco, and chewing tobacco will help reduce stomach acid and decrease GERD.
A reduction in body weight will decrease abdominal pressure and as little as five to seven pounds of weight loss may decrease GERD, especially when combined with the dietary changes mentioned above. Avoidance of restrictive garments and bending over after a meal will help decrease reflux. Ensuring that the evening meal is consumed at least four to five hours prior to bedtime will also decrease the probability of reflux occurring. Finally, elevating the head of the bed with four- to six-inch blocks may also decrease abdominal pressure, and thereby reduce the chance of reflux.
In summary, GERD is a significant medical condition causing symptoms of heartburn, difficulty and pain on swallowing and cough. It may, when inadequately treated, lead to a condition called Barrett’s esophagus, and even esophageal cancer. PPIs have proven to be an effective treatment for GERD. Nevertheless, PPI are strong medications with some significant side effects including possible increased risk of bowel infections, pneumonia, and malabsorption of minerals such as calcium and magnesium, leading to bone thinning and possible heart arrhythmias.
Implementation of a non-medicated approach to GERD may allow reduction in the dose of PPI and may allow discontinuation of PPI when not absolutely necessary. As such, diet and lifestyle may avoid the proverbial bottle of pills in the treatment of one of our most widespread and significant medical problems.
Paul E. Lemanski, MD, MS, FACP (firstname.lastname@example.org) is a board certified internist at the Center for Preventive Medicine, CapitalCare Medical Group in Albany. He is medical director of the Department of Community Medicine and Population Health at CapitalCare Medical Group. Paul has a master’s degree in human nutrition. He is an assistant clinical professor of medicine at Albany Medical College, and a fellow of the American College of Physicians.