when acid blockers don't work?
Gastroesophageal reflux disease (GERD) is one of the most common diseases seen in primary care practice. The most common presenting symptoms include heartburn, regurgitation and difficulty swallowing (dysphagia). The disease is often treated empirically with proton pump inhibitors (PPI) since the diagnosis is clinical. However, when a patient does not respond to either once or twice daily PPI therapy, should we consider refractory GERD?
Dr Philip Katz, interim chair, department of medicine, chair, division of gastroenterology, Einstein Medical Center, Philadelphia, Pa, who spoke on the topic of what to consider when PPI treatment isn’t enough at the 2015 American College of Gastronenterology Scientific Meeting, suggested asking a few fundamental clinical questions before referring to your friendly neighborhood gastroenterologist:
Typically, if the diagnosis of GERD is correct, a patient will receive some benefit with PPI therapy. Before searching for alternative diagnoses important to ensure that the patient is taking the medication correctly. Optimal PPI ingestion should be at least 30 minutes to an hour prior to food intake (capsules should not be opened, chewed, or crushed!) and all PPIs have similar efficacy. PPIs provide superior acid suppression in comparison to H2 blockers.
If medication is being taken appropriately, alternative diagnoses can be entertained (rumination, aerophagia, achalasia, functional heartburn or chest pain, gastroparesis, eosinophilic esophagitis as examples) and an endoscopy should be performed. If a patient has refractory GERD, there will be evidence on endoscopy (erosive esophagitis or Barrett’s esophagus). However, if nothing is found on endoscopy, the patient should have pH monitoring to prove that the symptoms correlate with episodes of reflux and expected drops in esophageal pH.
Should you stop the PPI before endoscopy? If there is a low pretest probability of GERD, test off the medication (7-10 days). However, if you have a high pretest probability of GERD, test on the PPI medication. If reflux monitoring (pH testing) is negative, the PPI can be stopped.
If pH monitoring validates acid reflux, and if PPI therapy and timing are optimized, surgical and pharmacologic options remain. Baclofen may offer potential salvage therapy (no placebo controlled trials yet). Alternatively, endoscopic options include radiofrequency ablation of the lower esophageal sphincter (in observational studies it has been shown to improve symptoms). Surgical candidates can consider transoral incisional fundoplication. It has been shown to significantly improve symptoms and reduce regurgitation in placebo controlled trials.
Magnetic sphincter augmentation directed at the lower esophageal sphincter-laparoscopically-implanted magnetized beads that are removable-has improved endpoints of heartburn, regurgitation, and PPI dependence.
If your patient does not get relief from a PPI, all is not lost. If symptoms persist and PPIs are being taken correctly, use endoscopy and Bravo pH monitoring (if endoscopy is negative). An individualized approach incorporating newer technologies may offer relief.
Reflux medications can bring some pretty significant relief to patients struggling with reflux and heartburn, especially if their reflux isn’t chronic. That being said, they don’t always work like they’re supposed to. Every patient is different, and there are many cases where medication isn’t an appropriate treatment for your symptoms. Here are 6 tell-tale signs that your acid reflux medication isn’t working:
Sign 1: You Continue to Get Symptoms of Heartburn
You continue to get chest pain or burning in the chest after eating. Even though you take your medication, this happens regularly. Your heartburn occurs every few days or daily with no relief in sight. Whether it occurs right away or an hour or two after eating, the symptoms make every day life miserable.
Sign 2: Your Symptoms Worsen When Resting or Sleeping
When you lie down after eating or sleep at night, you often wake up with heartburn or a stomach ache. Waking up late at night with heartburn is not enjoyable, and in many cases it can take hours to settle down and get back to sleep. This doesn’t just go for night-time reflux, though! If you’re waking up after a nap with indigestion, that’s another red flag. This is a sign your medication isn’t doing its job and eliminating your symptoms, so it may be time to consider an alternative like anti-reflux surgery.
Sign 3: Your Symptoms Occur After Eating
After eating a meal you experience heartburn, gas, and stomach upset. Big meals could be part of the problem, so eating smaller meals later in the day might help. Watch what you eat, just because you take medications for your reflux doesn’t mean you can eat whatever you want. Too much spicy or acidic food can cause symptoms even with medications. Still, if you’re noticing that your trigger foods are still causing heartburn, your medication is not working properly.
Sign 4: You’re Still Experiencing A Bitter Taste and Frequent Regurgitation
You’re still getting a sour taste in your mouth after a meal or just at random points throughout the day. It may come after breakfast, lunch, or dinner, disrupting your day. You may even get a bitter taste that wakes you up at night, causing you to wake up choking. This is not normal, especially if you’re taking acid reflux medications.
Sign 5: You’re Noticing Hoarseness and Extra Saliva
A great tell-tale sign that your reflux medication isn’t working properly is your voice. If you’re noticing that in the morning your voice is scratchy and you have to clear your throat frequently, you’re either catching a cold or acid is getting into your lungs from reflux. If it occurs often then it may be a sign the medication is not effective. Additionally, you may notice your mouth producing extra saliva. This is an indicator that you’re experiencing reflux, and it a sign that it’s time to call the doctor about your medication.
Sign 6: You’re A Bloated, Burping Nightmare
GERD occurs when acid reflux happens regularly. If a person experiences heartburn more than twice per week, it may be a sign of GERD.
About 20% of people in the United States have GERD.
Not everyone with GERD will experience heartburn. Other symptoms might include:
A doctor may recommend lifestyle changes and over-the-counter (OTC) or prescription medications to treat GERD.
OTC antacids can help to treat mild symptoms of GERD. However, a person will require different medications for more severe cases of GERD.
To treat more severe cases of GERD, a doctor may suggest H2 blockers or proton pump inhibitors (PPIs).
H2 blockers are medications that slow down acid production in the stomach. They can also help to heal the esophagus. A person can buy these as OTC medications, or a doctor can prescribe them.
PPIs also lower the amount of acid the stomach makes. They are effective at treating GERD symptoms and better at healing the esophagus lining than H2 blockers.
If treatment with medication is unsuccessful, a medical professional may recommend surgery.
Lifestyle changes could include:
If you find yourself reaching for acid reflux medication more than once a week, it’s time to see your healthcare provider for a thorough digestive health evaluation. But besides medications, there are other solutions that can give you relief from acid reflux symptoms. Please continue reading to learn more about what to do if your acid reflux medication is not working.
First, let’s take a quick look at the various terms used to describe burning chest pain, difficulty swallowing, and other symptoms that occur in the lower chest, especially after a fatty or heavy meal.
The burning pain, commonly called acid indigestion or heartburn, is a symptom of acid reflux. Acid reflux occurs when the lower esophageal sphincter (a sphincter muscle that acts like an anti-reflux barrier) is weak. A weak sphincter allows stomach acid to back up into the esophagus (food pipe) and irritate the tissues, causing heartburn symptoms. Gastroesophageal reflux disease (GERD) is a more severe and longer-lasting form of acid reflux.
It is okay to treat occasional heartburn and acid reflux symptoms with over-the-counter antacids. However, you should be properly evaluated for GERD by a healthcare professional if your symptoms occur frequently. Untreated or refractory gastroesophageal reflux disease can lead to serious health complications, including esophageal cancer.
Many people with heartburn who are taking GERD treatment still experience breakthrough symptoms. There could be several reasons why your acid reflux medication is not working effectively:
If you are experiencing a burning sensation in your chest more than once a week and taking medication frequently, it’s time to seek professional medical advice from a healthcare professional.
Your doctor will perform a thorough evaluation and make sure other medical conditions like heart disease are not causing your symptoms. They will also ensure your chronic acid reflux treatment is safe and adequate.
If the medications prescribed by your doctor do not provide relief from heartburn, down the line to treatment, there are surgical procedures available that can address the underlying problem.
Most people start by treating their acid reflux with over-the-counter medicines. Antacids like Tums, Mylanta, and Rolaids provide quick relief from acid reflux symptoms by neutralizing gastric acid in the stomach contents. But these heartburn drugs do not address the underlying cause of excess stomach acid, and they do not heal a damaged esophagus. Overuse of antacids can cause diarrhea and lead to health conditions like chronic kidney disease. Antacids should be taken after meals and at bedtime to achieve maximum efficacy.
H2 receptor blockers like Pepcid AC, Axid AR, and Tagamet HB work by decreasing the amount of stomach acid. This drug class is used to treat mild to moderate GERD. They are slower to start working but provide longer-lasting relief (up to 12 hours) compared to antacids. Long-term use of H2 receptor blockers can lead to tolerance and reduce the efficacy of therapy.
Proton pump inhibitors are stronger than H2 blockers and are often prescribed to GERD patients. PPIs block stomach acid production and also heal the esophageal lining. Examples include lansoprazole (Prevacid), omeprazole (Prilosec), and the combination product - Zegerid, containing omeprazole and sodium bicarbonate (baking soda). Long-term use of PPIs can lead to vitamin B12 deficiency, Clostridium-difficile (C.Diff) associated diarrhea, low blood magnesium levels, and an increased risk of bone fractures.
The safety and efficacy of alternative treatments, such as traditional Chinese medicine, herbal remedies, etc., are not scientifically proven by clinical trials. Always consult a healthcare provider before taking any alternative medicine to avoid drug interactions leading to undesirable side effects.
Most GERD patients benefit from medications and lifestyle changes and get relief from their symptoms. However, if they do not work, your doctor may recommend a minimally invasive procedure such as transoral incisionless fundoplication (TIF procedure), a Stretta procedure, laparoscopic fundoplication, or placement of the LINX Reflux Management System.
Proton pump inhibitors (PPIs) are the strongest prescription medications available for treating GERD. However, if you experience heartburn frequently, it’s important to seek medical advice from a health professional. PPIs should not be used constantly for the long term without the supervision and guidance of a healthcare professional. Long-term use of PPIs can lead to acute renal disease, chronic kidney disease, an increased risk of bone fractures, worsening cardiac conduction defects (a rare inherited heart rhythm disorder), community-acquired pneumonia, and C. difficile intestinal infection.
Lifestyle modifications can help many patients with acid reflux symptoms. Even if you are prescribed a GERD medication, long-term lifestyle changes are essential for maintaining GERD symptoms. Some of the lifestyle changes you can try include:
Most adults with GERD take certain medications to help reduce the acid in their stomach. Some of those meds are over the counter and others are prescription. This is usually the first line of treatment for GERD.
Histamine Type 2 blockers can be found over the counter or your doctor may prescribe something with a higher dose. They also help to heal your esophagus, but they direct you to take them only when you have symptoms.
They include the following:
Proton Pump Inhibitors (PPIs) are similar to type 2 blockers, but they usually work better. The main difference is you take them on a daily basis regardless of symptoms. They include Prilosec, Prevacid. Nexium, Protonix, and Aceplex.
Antibiotics can help you digest your food faster, therefore, there are less symptoms.
Prokinetics are similar but there can be side effects.
When your symptoms are stronger than PPIs and Type 2 blockers can relieve, Digestive Health Services, SC may recommend other treatments. Endoscopic procedures and surgery may be the next step.
The goal of endoscopic procedures is to tighten the muscles between the stomach and the esophagus. A tiny tube is inserted into your mouth and down the esophagus. The muscle is tightened by stitches or heating a small area with radiofrequency energy.
Surgery for GERD is known as Fundoplication. It is a minimally invasive procedure and entails wrapping the top part of the stomach around the lower section of the esophagus. This helps to prevent food and acid from coming back into the esophagus.
If medications don't provide relief, further treatment options might include procedures intended to repair or replace the valve that connects the stomach and esophagus, which is often the culprit for acid reflux. They include: Laparoscopic fundoplication. Transoral incisionless fundoplication.
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