Acid Reflux Treatment

Lifestyle Changes

For many GERD sufferers, symptoms can be alleviated with a change of lifestyle. Current medical research recommends seven changes that may relieve GERD/LPR symptoms:

1. Obesity

The most significant risk factor associated with GERD is obesity. An overwhelming number of studies show a strong correlation between obesity and acid reflux. (1) (2)  Obese people are thought to have higher intra-abdominal pressure due to too much fatty tissue that causes more transient lower esophageal relaxations. (3) (4) (5)

Weight loss is therefore recommended for GERD sufferers who are overweight. One study found weight loss over a six month period resulted in a reduction of GERD symptoms in 81% of its patients and complete symptom resolution in 65% of patients. (4) Another study showed a 22% reduction in acid reflux symptoms due to weight loss. (6)

2. Tobacco

The second risk factor associated with GERD is tobacco use. Tobacco use has been noted to double the risk of developing esophageal adenocarcinoma, a cancer associated with GERD. (7) (8) In one large prospective cohort study, normal weight GERD patients who cease tobacco use experienced reduced reflux symptoms. (6)

3. Alcohol

There is a significant correlation between alcohol consumption and GERD/LPR. If you have GERD you should moderate your alcohol consumption or completely abstain. (9) Alcohol relaxes the lower esophageal sphincter and can increase the chances of acid reflux.

4. Smaller Meals

4-6 smaller meals throughout the day may alleviate reflux symptoms, support LES closure and reduce bloating. (10)

5. Eat Earlier

Having dinner at least 2-3 hours before bedtime can decrease the duration of acid exposure especially for silent reflux/LPR sufferers. A study reported patients who had their meal 6 hours before bedtime experienced less acid reflux than those who had their meal 2 hours before bedtime. (6)

Because TLESRs occur most frequently after a meal, laying down too soon after eating could cause acid reflux.  (4) (7) (11)  This study suggests it may be beneficial to eat dinner at least 3 hours before you go to bed. There is some evidence however that many GERD patients who suffer from refractory GERD may experience reflux episodes in the upright position. (12) For these patients, earlier eating times may not be beneficial.

6. Raise the Head of your Bed

Elevating the head of your bed may help alleviate GERD/LPR symptoms. One study reported a 5% decrease in acid exposure in subjects with an elevated bed compared to subjects without an elevated bed. The head of the bed should be elevated 5-8 inches (12)

7. Acidic Foods

Certain foods such as citrus, tomato, chocolate, coffee, soda, peppermint, and fatty foods may induce GERD symptoms, such as heartburn in some people. However, some GERD/LPR patients may experience no symptoms eating these foods.

GERD patients should monitor their response to these foods in a journal and limit intake if adverse symptoms are experienced.

Medications

Drugs like anticholinergics, theophylline, alendronate, antidepressants, calcium-channel blockers, antibiotics, narcotics, bisphosphonates and non-steroidal anti-inflammatory drugs can cause or exacerbate GERD symptoms by relaxing the lower esophageal sphincter (13).

Talk to your physician or pharmacist for more information on drugs that are known to cause GERD and whether you can substitute for a drug that does not affect the lower esophageal sphincter.

Drug Therapy

PPIs

PPIs are among the top most prescribed medications in the United States, generating almost 14 billion dollars in sales per year. (14) PPIs include omeprazole, esomerprazole magnesium, lenosoprazole, rabeprazole, and pantoprazole. (15) Omeprazole (Prilosec), esomeprazole magnesium (Nexium), and lansoprazole (Prevacid) are the most popular PPIs.

PPIs are currently the gold standard used to treat acid reflux by suppressing the amount of acid the stomach produces. Less stomach acid leads to less acid potentially damaging the esophagus and gives the esophagus time to heal. PPIs are usually prescribed to be taken once-twice a day before the first meal or before dinner for night time reflux/LPR sufferers. (16)

If patients do not respond to a single dose, a double dose of PPIs are generally prescribed. Patients who do not experience symptom relief at all may undergo an endoscopic evaluation to check for other possible causes.

Ideally, patients who respond well to PPI acid reflux treatment should be given the lowest effective dose to avoid complications from long-term use and benefit from significant cost savings. (4) (16)

PPI Risks

Long-term PPI use may increase the risk of clostridium diffile infection, microscopic colitis, hip fracture, B12 vitamin deficiency, spine fracture, and even heart attacks and Alzheimer’s disease. (15) (17) (18) Studies conducted in 2015 and 2016 linked PPIs to dementia and kidney damage.

Ineffectiveness of PPIs

And it turns out PPIs may not even work for a large number of people. 30 to 50% of GERD patients on PPIs still experience reflux symptoms and a large number of PPI users still develop serious reflux-related complications like Barrett’s Esophagus and cancer. (14) (19) (20) Another study reported an 80% recurrence rate of esophagitis in GERD patients who completed initial PPI therapy (3) (16)

Regurgitation, the hallmark of GERD, despite therapy is also difficult to relieve even with high doses of PPIs. (20) Even if patients initially respond to PPI therapy, the medication may partially or completely lose its effect years later. (21)

PPIs do not work for many LPR Patients

PPIs also been have not been proven effective against LPR and extraesophageal symptoms. The Cochrane review conducted a review of PPI response in LPR patients and was not able to establish PPI superiority over a placebo in PPI users. (22)

A separate cohort study that administered 20 mg of PPI medication to LPR patients three times daily only yielded a response rate of 47% and 63% at the 6 and 12-week mark. (23)

Ultimately, patients with extraesophageal symptoms like hoarseness and laryngitis who do not respond to aggressive PPI therapy most likely do not have GERD (24).

The medical community coins those who experience less than 50% improvement of reflux symptoms despite 12 or more weeks of PPI therapy as patients with refractory GERD. (25) Refractory GERD is thought to be caused by acid hypersensitivity, though the research is still uncertain. (25) (26) Another theory suggests that patients with refractory GERD suffer from other stomach disorders such as rumination syndrome.

Patients who have refractory GERD are usually presented with the option of reflux surgery but the success rate of anti-reflux surgeries is often mixed.

Antacids

Antacids like Tums remain one of the most popular and accessible heartburn drugs on the market. They work by reducing the acidity of stomach contents and neutralizing them.

Antacids may not work for everyone as they are not able to withstand repeated acid secretions for more than 30 minutes before losing its neutralizing effect. (17)

Histamine Blockers

Histamine blockers act as second-line reflux drugs by blocking histamine H receptors in cells and limiting acid secretion. (15)  Commonly prescribed histamine blockers are ranitidine, famotidine, cimetidine, and nizatidine. The main side effect of this drug is rash, but this is very rare.

Prokinetic Drugs

Prokinetic drugs accelerate the emptying of food by stimulating muscle contractions in the stomach. The most commonly used prokinetic drugs are metoclopramide and domperidone.

These drugs are less commonly used than PPIs and should be used with caution as they are known to cause a wide variety of dangerous side effects. Reported side effects of these drugs include restlessness, sedation, diarrhea, depression, irregular heartbeat, hives, confusion, fever, and frequent urination. (13)

  • Metoclopramide can cause a condition called tardive dyskinesia, a condition that causes uncontrollable bodily movements such as chewing, scowling, mouth puckering, sticking out the tongue, and shaking the arms and legs.

  • Cisapride, a once-promising prokinetic drug for treating acid reflux was pulled from the market in 2000 for causing cardiac problems and was implicated for at least 80 deaths.

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