Digestion, health and nutrition: Dr. Anil Minocha, a gastroenterologist and nutritionist

GERD Acupuncture treatment

Did you know that acupuncture may be an effective GERD or chronic reflux treatment?

Gastroesophagaeal reflux disease or GERD affects tens of millions of people in the US. Proton pump inhibitors (PPIs) are the most effective medical therapy. Patients on PPI therapy are usually started on once a day dosing. However, many patients require double dose, i.e. twice a day dosing for PPIs for relief of reflux symptoms.

Long term use of PPIs is not without long term side-effects.  Many patients choose to employ complementary and alternative medicine therapies instead. Chinese medicine is an ancient system of holistic medicine effective for treatment of variety of gastrointestinal and non-digestive disorders as well as mental conditions and has been used in this context.

Dickman and colleagues examined whether addition of acupuncture rather than another dose of PPI (omeprazole) to the regimen of once a day PPI dose for GERD would be beneficial. Acupuncture was conducted at 5 points selected to calm the stomach system. The investigators found a dramatic difference in relief by addition of acupuncture to the regimen as compared to another dose of omeprazole.

Acupuncture may work better since it treats whole body acting at multiple processes than stomach acid alone.

Do you have chronic heartburn or GERD? What treatment to you take? What are your thoughts on long term use of PPIs versus use of alternative and complimentary therapy like acupuncture. If you are taking medical treatment for GERD, would you be willing to add or even substitute it with some form of CAM? Please share your thoughts.

Yes, heartburn without acid reflux

Do you have chronic heartburn or GERD? Did you know that many patients with heartburn (chronic acid reflux) or gastroesophageal reflux disease (GERD) do not get relief even from the strongest acid blocking medications also known as proton pump inhibitors PPIs. Lack of response in "GERD" or chronic reflux patients may occur due to a variety of reasons which include:

1. Some patients may require higher than normal dose, for example twice a day PPI instead of once a day. This can be documented by doing 24 hour pH monitoring while taking the medication.
2. Although heartburn in majority of patients is due to acid reflux, it may be also occur as a result of reflux of non-acid gastric contents into the esophagus. Obviously, acid blocking medications are not going to help if the refluxate does not have much acid. These patients may be helped by anti-reflux surgery to prevent any kind of reflux.
3. A small fraction of patients may have symptoms of heartburn in the absence of any kind of reflux, acid or non-acid. Assuming cardiac etiology has been excluded, this is believed to be in part due to lowered pain threshold. Medications that raise pain threshold may be helpful to some extent. A combined pH monitoring and impedance testing can help distinguish this from acid and non-acid reflux.

Do you or someone you know have GERD or heartburn? What treatments have been effective and to what degree? Please feel free to share your thoughts. By the way, do not forget the potential benefit of lifestyle measures on chronic gastroesophageal reflux disease.

Are over the counter heartburn drugs effective?

There has been an explosion in the market for over the counter heartburn drugs like antacids, alginate/antacid combinations as well as histamine2 receptor blockers (H2B or H2RAs). The question arises, how effective are these OTC drugs?

Dr. Tran and colleagues from the Baylor College of Medicine in Houston, TX recently carried out a systematic review and meta-analysis of randomized placebo controlled trials related to these therapies. They published their findings in the journal Alimentary Pharmacology and Therapeutics (Jan 2007).

Studies conducted with H2Ras showed superiority of these drugs with respect to complete relief of heartburn, symptomatic improvement, and episodes requiring rescue antacids. There was an absolute benefit increase of 10-12 percent with this class of medications.

Based on the four studies examining the antacids, the authors found a trend towards their effectiveness with an absolute benefit of 8 percent.

Similarly, 4 studies examining the demonstrated alginate/antacid combination found this class to be superior to placebo with an absolute benefit of 26 percent.

An amazing finding was the effect of placebo. The authors found that placebo response occurred in 37 to 65% of the cases.

Recently, omeprazole a proton pump inhibitor has become available without a prescription. However, OTC omeprazole was not studied in this report.

Do you suffer from heartburn, chronically or intermittently? Do you frequently take OTC drugs? Which one is your favorite?

Risks of PPI heartburn drugs keep piling up

Proton pump inhibitors or PPIs (Prilosec, Prevacid, Nexium, Protonix, Aciphex) have been a big boon to the chronic heartburn or GERD sufferers. These PPI drugs started with a black box label warning of serious consequences of cancer to being used indiscriminately almost like a candy. Data indicate that a substantial proportion of long-term PPI users do not have a clear indication for their therapy and there is thus room for reduction or rationalization of treatment.

Long term use of proton pump inhibitors is providing us increasing information on their potential harmful effects. Recent data about PPIs suggests the following:

1. Increased risk of serious intestinal infections with Clostridium difficile bacteria
2. Increased risk of bone fractures
3. Bad breath
4. Bacterial overgrowth
5. Diarrhea and microscopic colitis
6. Vitamin B12 deficiency
7. Chronic muscle disease (myopathy, polymyositis)

Heartburn drugs may cause bad breath

It is believed that chronic heartburn or gastroesophageal reflux disease (GERD) causes bad breath or halitosis. Acid blocking medications have often been used for this purpose. Now comes a study suggesting that the opposite is in fact true, i.e. the potent heartburn drugs of the proton pump inhibitor (PPI) class e.g. Aciphex, Prilosec, Prevacid, Nexium, Protonix etc. may actually cause bad breath.

Dr. Camacho-Lobato and colleagues from Brazil recently presented their findings at the American College of Gastroenterology meeting in Las Vegas in October 2006 (Poster#8).

The researchers studied 23 consecutive adults with GERD. And compared them to 17 patients with dyspepsia or indigestion. Patients with oral or dental disease were excluded. Oral volatile sulphur compounds that cause bad odor in breath were measured.

These investigators found that bad breath occurred in 39 percent of the GERD as compared to only 18% in those with dyspepsia.

Because of their potent acid blocking activity, PPI have potential to cause small bowel bacterial overgrowth thus causing bad breath.

This study represents a classic chicken and egg story. Is it that GERD causes bad breath and patients were simply taking PPIs to alleviate GERD. The reverse is also possible, i.e. the halitosis occurs due to acid blocking by these drugs in GERD, and contributes to the bad breath problem caused by GERD itself also.

Do you have chronic heartburn and/or bad breath? What measures do you take for these problems?