Breaking down diabetes
In the last 20 years, the number of adults diagnosed with diabetes has more than doubled.
What is that pain in my throat or my chest? Was it something I ate at dinner? Am I having a heart attack or just an intense bout of heartburn?
According to the American College of Gastroenterology, acid indigestion, i.e. heartburn, affects an estimated 60 million Americans each month. If, after eating, the familiar pain of heartburn starts to flare, then situational reflux is likely to blame. While occasional bouts of situational heartburn can be managed using over-the-counter antacids such as Rolaids® or TUMS®, they are not ideal for long-term recurrent bouts of acid. If a person experiences reflux several times a week, or it is accompanied by other symptoms like nausea, vomiting, regurgitation, or bloating, it may be time to schedule an appointment with a reflux specialist to discuss whether or not they are symptoms of GERD.
Left untreated, the overproduction of acid can lead to peptic ulcers and, in severe cases, a pre-cancerous condition called Barrett’s Esophagus. The main treatments recommended for treating GERD are:
The first step in minimizing symptoms of GERD is to limit foods that trigger reflux. As reflux can sometimes be delayed in onset, it is valuable to keep a journal of the foods eaten and when symptoms begin. Foods that trigger reflux vary from person to person, but commonly fried foods, coffee, chocolate, spicy foods, carbonated drinks, and peppermint will cause reflux. Once the foods are identified, an elimination diet can be implemented to determine whether or not symptoms improve.
Since Omeprazole’s introduction in 1988, Proton-Pump Inhibitors (PPIs) have become the primary course of treatment for gastroesophageal reflux disease, with PPIs being one of the most widely prescribed medications across the world. PPIs have shown efficacy in reducing bothersome symptoms. Additionally, PPI utilization can assist a treating physician in determining if surgery or other procedures will be necessary to eliminate symptoms if PPIs don’t prove successful in eliminating symptoms.
Other medications, such as H-2 blockers like Zantac (ranitidine), are used to block acid producing cells in the stomach. However, in 2020 the FDA issued a recall of all versions due to a potential cancer risk. Recently, the medication was relaunched with a new name (Zantac 360) and a different ingredient (famotidine), which is also the active ingredient for Pepcid.
There is no doubt that PPIs are capable of managing some of the symptoms of GERD. However, estimates vary, suggesting between 25% to 70% of patients remain on long-term PPI therapy unnecessarily. When the Washington State Health Care Authority introduced duration and dose limits for PPIs to one tablet/capsule per day for two months during any 12-month period unless chronic medical conditions necessitated their use, they used the following reasoning: “PPIs are commonly prescribed to treat gastroesophageal reflux disease (GERD) or heartburn, and symptoms are generally well controlled after 60 days of PPI therapy, even when cases are more severe. PPIs are known to cause rebound acid reflux when patients try to abruptly discontinue using the PPI. This rebound reflux is often mistaken for continued need of the PPI and has led to overutilization.”
With increasing amount of research suggesting correlations between PPIs and medical conditions such as increased risk of osteoporosis-related fractures, kidney disease, and stroke, not only is this potentially unnecessary long-term prescription of PPIs expensive, but it also inappropriately exposes a significant number of people to the side effects of PPI therapy. Further research still needs to be done to link causation and not just correlation, but anyone taking PPIs should discuss the potential risks of long-term use with their doctor. With the understanding that PPI’s have the potential to cause adverse long-term effects, what other options exist for the treatment of GERD when medication and lifestyle modifications don’t work?
With GERD being one of the most common conditions seen in the adult population, it is not a surprise that all patients aren’t helped by medication and/or lifestyle modifications. The Nissen Fundoplication procedure creates a sphincter in the esophagus in an attempt to prevent future acid reflux. Before performing this surgery, the surgeon may order GI x-rays, an esophageal manometry, upper endoscopy or a pH probe, all in an attempt to assess any narrowing of the esophagus. The procedure can be done laparoscopically or as an open procedure, which allows for more range of motion. In both procedures, general anesthesia is used, with the end result being the upper stomach is wrapped around the lower esophagus, creating a new sphincter. Unfortunately, like any surgery, results can’t be guaranteed, and symptom relief does not always last. Some patients can need another surgery after two to three years.
While heartburn is incredibly common, there is not a consistent standard for addressing the problem. Some suffers might be willing to make every lifestyle modification available to avoid symptoms. However, others might be willing to keep a steady supply of TUMS® in the car, on the dresser, and at work. For those that find medication works best, IPM always recommends plan sponsors keep generic PPIs on their approved formulary. If you are one of the 60 million sufferers, the question becomes, what are you going to do about it?