Gastroesophageal reflux disease (GERD) is estimated to affect 10-20% of the Western world and up to 30 million people in the United States alone.1 Increased stress may be a contributor to GERD symptoms, and clinical studies have suggested a relationship between GERD and anxiety, as well as depression,2 which may become an increasingly important clinical consideration during the COVID-19 pandemic.
The most popular GERD treatments, stomach acid reducers, are a booming business, with both H2 blockers and proton pump inhibitors (PPIs) used widely. Prescription PPIs are used by an estimated 15 million Americans.3 Taking an over-the-counter acid blocker for occasional heartburn symptoms may not be a big issue, but in practice, many patients with chronic reflux are prescribed acid blockers indefinitely. A significant number of researchers have independently linked PPIs to adverse health problems such as bone fractures,4 chronic kidney disease,5 and pneumonia,4 among others.
Given these risks, is there a better way to treat the increasingly common issue of GERD? In the following video, IFM educator Shilpa P. Saxena, MD, IFMCP, talks about the non-gastrointestinal symptoms of GERD, such as allergies, and identifies some of the steps she takes when developing a treatment plan.
PPIs: Comparing the Pros and Cons
When establishing treatment for patients who require acid suppression, considering PPI benefits and risks associated with dosage amounts and duration is an important component.
Not all research suggests that PPIs are associated with adverse effects. For example, a three-year randomized trial of pantoprazole completed in 2019 did not find significant adverse events, with the exception of an increased risk of enteric infections.6 PPIs continue to be a primary therapy for acute and long-term management of GERD due to their:
- Effectiveness in controlling GERD symptoms and potentially arresting disease progression.7
- Improvement of healing rates and fewer relapses in patients with erosive esophagitis compared to H2 blockers.8
- Consistent superiority compared to earlier drugs for relieving GERD symptoms.8
Guidelines recommend using the lowest dosage of stomach acid reducers for symptom relief; however, these medications are often used in excessive doses or duration.7 According to warnings posted by the US Food and Drug Administration (FDA), long-term use of PPIs may not only lower serum magnesium levels, it may also increase fracture risk.9,10 Several recent research studies have noted a range of additional adverse effects from the use of acid blockers:
- A 2017 meta-analysis of 7,703 patients found that the use of gastric acid suppressants was associated with a significantly increased risk of recurrent difficile infection (CDI).11 Risk factors for recurrent CDI include older age, concomitant antibiotic use, and comorbid conditions.11
- Meta-analyses suggest that PPI use is a potential risk factor for small intestinal bacterial overgrowth, spontaneous bacterial peritonitis, community-acquired pneumonia, hepatic encephalopathy, and adverse outcomes in inflammatory bowel disease.12
- A 2019 cohort study linked the long-term use of these drugs to fatal cases of cardiovascular disease, chronic kidney disease, and upper gastrointestinal cancer.13
Lifestyle Modifications & Alternate Therapies
Instead of long-term pharmaceutical use, personalized treatment strategies that include lifestyle modifications and alternate therapies may help patients with chronic reflux conditions find consistent and effective symptom relief and recovery.
Lifestyle modifications that have been studied for GERD include weight loss, head-of-bed elevation, and avoidance of tobacco, alcohol, and late-night meals.14-16 Another modification that has been suggested is avoiding large meals and those foods that may aggravate reflux symptoms—e.g., caffeine, coffee, chocolate, spicy foods, highly acidic foods (oranges, tomatoes), and fatty foods.
Alternate and complementary GERD treatments are under continued investigation and include methods such as reflux inhibitors, prokinetics, acupuncture, and hypnotherapy.8 A variety of studied GERD interventions have shown promising results, such as alginate-based therapies17 and breathing exercises18 to reduce symptoms and mindfulness-based stress reduction to improve health-related quality of life.19
Going forward, some Functional Medicine clinicians have successfully transitioned patients from PPIs to H2 blockers, which may have fewer side effects. It may be easier than transitioning them off of H2 blockers entirely. It is important to note that there has been some concern regarding acid rebound when weaning patients off of PPIs.20 The Functional Medicine framework can be particularly useful for clinicians if this tapering process is appropriate for a patient’s personalized treatment plan.
IFM teaches clinicians how to identify the underlying conditions of gastrointestinal concerns and how to develop and organize individual treatment protocols using lifestyle, diet, nutraceuticals, pharmaceuticals, and botanicals, as well as providing educational materials for patients to prioritize their lifestyle treatments. Clinicians looking for tools and strategies to help prevent GERD, address problems with the microbiome, and improve overall gastrointestinal function can attend IFM’s upcoming GI Advanced Practice Module (APM).
- Tabrez ES, Hussain A, Rao S, Jagadeesh A, Peela JR, Tabrez SSM. Gastroesophageal reflux disease: a review of symptomatic management. Crit Rev Eukaryot Gene Expr. 2018;28(1):87-92. doi:10.1615/CritRevEukaryotGeneExpr.2018022767
- On ZX, Grant J, Shi Z, et al. The association between gastroesophageal reflux disease with sleep quality, depression, and anxiety in a cohort study of Australian men. J Gastroenterol Hepatol. 2017;32(6):1170-1177. doi:10.1111/jgh.13650
- Aitken M, Kleinrock M, Lyle J, Caskey L. Medicine Use and Shifting Costs of Healthcare: A Review of the Use of Medicines in the United States in 2013. IMS Institute for Healthcare Informatics; 2014. Accessed April 22, 2020. https://democrats-oversight.house.gov/sites/democrats.oversight.house.gov/files/documents/IMS-Medicine%20use%20and%20shifting%20cost%20of%20healthcare.pdf
- Takagi T, Naito Y, Inoue R, et al. The influence of long-term use of proton pump inhibitors on the gut microbiota: an age-sex-matched case-control study. J Clin Biochem Nutr. 2018;62(1):100-105. doi:10.3164/jcbn.17-78
- Li T, Xie Y, Al-Aly Z. The association of proton pump inhibitors and chronic kidney disease: cause or confounding? Curr Opin Nephrol Hypertens. 2018;27(3):182-187. doi:10.1097/MNH.0000000000000406
- Moayyedi P, Eikelboom JW, Bosch J, et al. Safety of proton pump inhibitors based on large, multi-year, randomized trial of patients receiving rivaroxaban or aspirin. Gastroenterology. 2019;157(3):682-691.e2. doi:10.1053/j.gastro.2019.05.056
- Schnoll-Sussman F, Niec R, Katz PO. Proton pump inhibitors: the good, bad, and ugly. Gastrointest Endosc Clin N Am. 2020;30(2):239-251. doi:10.1016/j.giec.2019.12.005
- Young A, Kumar MA, Thota PN. GERD: a practical approach. Cleve Clin J Med. 2020;87(4):223-230. doi:10.3949/ccjm.87a.19114
- US Food and Drug Administration. FDA drug safety communication: possible increased risk of fractures of the hip, wrist, and spine with the use of proton pump inhibitors. Updated March 23, 2011. Accessed April 23, 2020. https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/fda-drug-safety-communication-possible-increased-risk-fractures-hip-wrist-and-spine-use-proton-pump
- US Food and Drug Administration. FDA drug safety communication: low magnesium levels can be associated with long-term use of proton pump inhibitor drugs (PPIs). Published March 2, 2011. Accessed April 23, 2020. https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-low-magnesium-levels-can-be-associated-long-term-use-proton-pump
- Tariq R, Singh S, Gupta A, Pardi DS, Khanna S. Association of gastric acid suppression with recurrent Clostridium difficile infection: a systematic review and meta-analysis. JAMA Intern Med. 2017;177(6):784-791. doi:10.1001/jamainternmed.2017.0212
- Naito Y, Kashiwagi K, Takagi T, Andoh A, Inoue R. Intestinal dysbiosis secondary to proton-pump inhibitor use. Digestion. 2018;97(2):195-204. doi:10.1159/000481813
- Xie Y, Bowe B, Yan Y, Xian H, Li T, Al-Aly Z. Estimates of all cause mortality and cause specific mortality associated with proton pump inhibitors among US veterans: cohort study. BMJ. 2019;365:l1580. doi:10.1136/bmj.l1580
- Alzubaidi M, Gabbard S. GERD: diagnosing and treating the burn. Cleve Clin J Med. 2015;82(10):685-692. doi:10.3949/ccjm.82a.14138
- Park SK, Lee T, Yang HJ, et al. Weight loss and waist reduction is associated with improvement in gastroesophageal disease reflux symptoms: a longitudinal study of 15,295 subjects undergoing health checkups. Neurogastroenterol Motil. 2017;29(5):e13009. doi:10.1111/nmo.13009
- Surdea-Blaga T, Negrutiu DE, Palage M, Dumitrascu DL. Food and gastroesophageal reflux disease. Curr Med Chem. 2019;26(19):3497-3511. doi:10.2174/0929867324666170515123807
- Leiman DA, Riff BP, Morgan S, et al. Alginate therapy is effective treatment for GERD symptoms: a systematic review and meta-analysis. Dis Esophagus. 2017;30(5):1-9. doi:10.1093/dote/dow020
- Qiu K, Wang J, Chen B, Wang H, Ma C. The effect of breathing exercises on patients with GERD: a meta-analysis. Ann Palliat Med. 2020;9(2):405-413. doi:10.21037/apm.2020.02.35
- Chandran S, Raman R, Kishor M, Nandeesh HP. The effectiveness of mindfulness meditation in relief of symptoms of depression and quality of life in patients with gastroesophageal reflux disease. Indian J Gastroenterol. 2019;38(1):29-38. doi:10.1007/s12664-019-00940-z
- Pandolfino J. Discontinuation of proton pump inhibitor therapy and the role of esophageal testing. Gastroenterol Hepatol (NY). 2013;9(11):747-764.