The Connection Between Asthma and Acid Reflux

Why these sometimes occur together—and what to do about it

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Asthma (a chronic respiratory condition) and acid reflux (when stomach acid backs up into the esophagus) are more related than they may seem.

Asthma can cause the lower esophageal sphincter (LES)—a muscular ring at the junction of the esophagus and stomach—to relax, allowing stomach acid to flow upward. And acid reflux can cause airway irritation and stimulate nerves, triggering inflammation or narrowing of the airways that leads to asthma symptoms or asthma attacks.

The connection between the two conditions poses a particular challenge when it comes to management: Those with asthma are at an increased risk for gastroesophageal reflux disease (GERD), acid reflux occurring a few times a week or more. This commonly contributes to uncontrolled asthma; as many as 75% of patients with difficult-to-treat cases note that they frequently experience heartburn, a classic GERD symptom.

Unfortunately, many of the very medications recommended to help keep asthma in check can worsen symptoms of GERD—and so the cycle of influence continues.

Young woman using inhaler
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Symptoms

In exploring how asthma and acid reflux can affect one another, it's helpful to know the symptoms they can cause independently, as well as how those symptoms can overlap.

Symptoms of acid reflux include:

  • Heartburn (pyrosis): This is the painful burning in your stomach and mid-chest caused by acid from your stomach going up into and irritating your esophagus. This is the most common symptom of GERD, which can also lead to worsening asthma control.
  • Regurgitation: Many patients will describe the sensation of acid and food backing up into the esophagus as a "wet burp." Some people also have a sensation that their food is always coming back up with a sense of nausea.
  • Sour or bitter taste in the mouth: Depending on the severity, reflux may cause a sour or bitter taste, or you may get a sudden sensation of a salty fluid in your mouth called water brash.

GERD can also cause some less common symptoms:

  • Nausea
  • Chest pain
  • Difficulty or pain while swallowing
  • Persistent sore throat
  • Hoarseness or voice changes
  • Chronic cough

There are some similarities with the four classic symptoms of asthma:

When acid reflux is also present, some of these symptoms may be compounded (and vice versa).

Symptoms of an asthma attack can include severe wheezing, severe chest pain, very rapid breathing, difficulty talking due to shortness of breath, bluish skin, and profuse sweating. If you experience any of these or have regular symptoms that don't respond to your asthma medication, seek urgent medical attention.

Your doctor may suspect that asthma and acid reflux may be occurring together in these scenarios:

  • Asthma symptoms continue despite taking medication appropriately or you have had a poor response to your treatments.
  • Asthma worsens after eating foods that make reflux worse, such as a high-fat meal, alcohol, chocolate, or caffeine. Asthma may also worsen after eating large meals.
  • You're taking asthma medications that may increase reflux, such as albuterol (a type of rescue inhaler for acute symptoms), prednisone (a type of oral corticosteroid), or theophylline (a bronchodilator typically used as a long-term controller medication)
  • Your asthma symptoms began as an adult.
  • You have unexplained nighttime asthma symptoms: If your asthma is uncontrolled, especially if you are having nighttime symptoms, GERD may be to blame. Aside from the fact that symptoms of both conditions may worsen at night independently, you may not be aware that your reflux is severe enough that you are actually aspirating food particles into your lungs while you are sleeping or lying down, which may be what is causing your restlessness and asthma symptoms.
Reflux Symptoms
  • Hearburn

  • Regurgitation

  • Sour or bitter taste in the mouth

Asthma Symptoms
  • Wheezing

  • Chest tightness

  • Shortness of breath

  • Chronic cough

Causes

Many people get acid reflux occasionally, but if it's a frequent and ongoing issue, it may be due to a weakness or malfunctioning of the LES.

Things that can affect the LES and contribute to acid reflux and GERD, or make symptoms, worse include:

Possible asthma risk factors include:

  • A family history of asthma or inherited genes that affect how the immune system develops
  • Exposure to frequent viral infections in early childhood
  • Poor air quality from pollutants
  • Multiple allergies, such as food allergies and/or allergies to animal dander or pollen
  • Airway hyperreactivity (an exaggerated airway responsiveness to various stimuli)
  • Exposure to chemical irritants or industrial dusts

Of great importance in this context are two risk factors that apply to both conditions:

  • Excess weight/obesity
  • Smoking or exposure to secondhand smoke
Reflux Causes
  • Weakness or malfunctioning of the lower esophageal sphincter due to factors such as pregnancy, excess weight, or smoking

  • Medications, including some asthma medications

  • Hiatal hernia

Asthma Causes
  • Genetic predisposition and environmental factors (risk factors)

  • Strong response of the immune system to a substance in the lungs

  • Triggers such as allergens, cigarette smoke, and industrial chemicals

Diagnosis

Acid reflux and GERD are often diagnosed based on symptoms and a treatment trial that may include lifestyle interventions and taking medication that suppresses acid production for four to eight weeks.

If you have asthma and your physician suspects you may also have GERD, they may immediately start such a therapy trial to see if your symptoms improve.

If they don't, lab and imaging tests may be ordered to diagnose GERD and/or rule out other gastrointestinal conditions. These can include:

  • Esophageal pH monitoring: Either a catheter is guided through the nose to the esophagus or a small capsule is placed on the lining of the esophagus to monitor acid levels for 24 to 48 hours. These types of monitoring are the most accurate for diagnosing GERD.
  • Upper endoscopy: A tube with a camera is guided through the mouth, esophagus, stomach, and upper part of the small intestine to examine the digestive tract and take biopsies if needed.

Asthma is diagnosed based on family and personal medical history, a physical exam, and results from diagnostic tests like the following. These may be ordered if you are showing signs of asthma in addition to your reflux symptoms.

  • Pulmonary function tests, such as spirometry or peak expiratory flow (PEF), measure how much and how quickly your lungs expel air during a forceful exhalation.
  • Bronchodilation and bronchoprovocation tests measure your lungs' response after being given asthma medication or after an intentional disturbance to normal airflow. Spirometry is used before and after the medication or disturbance.
  • Fractional exhaled nitric oxide (FeNO) tests measure levels of nitric oxide when you exhale.
  • Skin or blood tests may be done to test for allergies.
Diagnosis of GERD
  • Acid reflux that occurs more than twice per week

  • Treatment trial with medication to see if symptoms improve

  • If symptoms don't improve, diagnostic tests such as esophageal PH monitoring

Diagnosis of Asthma
  • Chronic symptoms (wheezing, chest tightness, shortness of breath, cough)

  • Physical exam and medical history

  • Pulmonary function tests

  • Skin or blood tests for allergens to diagnose allergic asthma

Treatment

Treatments for GERD and treatments for asthma focus on a combination of prevention and control of symptoms when they occur. If you are diagnosed with asthma, your physician will also help you develop a personalized asthma action plan to help you recognize triggers, such as those related to GERD, and what steps to take based on symptoms.

Lifestyle Changes

There are a variety of lifestyle strategies that can be used to manage and prevent symptoms of acid reflux and asthma.

Your provider may offer you a number of possible dietary and lifestyle interventions for acid reflux, such as:

  • Avoiding or reducing your intake of drinks and foods that can worsen reflux, such as alcohol, fried foods, chocolate, and caffeinated drinks
  • Instead of the standard three meals a day, eating smaller meals more often
  • Avoiding eating or drinking three hours before lying down
  • Elevating the head of your bed by several inches to use gravity as a method of keeping acid in the stomach
  • Quitting smoking
  • Losing weight if you are overweight or obese: Even a loss of just a few pounds is sometimes enough to improve symptoms.
  • Avoiding tight-fitting clothes that increase pressure in the abdomen and make reflux more likely

Lifestyle interventions for asthma may include:

  • Identifying asthma triggers and reducing or avoiding exposure to them
  • Environmental interventions, such as mold remediation, to reduce exposure to allergens
  • Quitting smoking or reducing exposure to secondhand smoke
  • Getting regular physical activity
  • Developing a plan to manage or reduce stress
  • Maintaining good sleep habits, such as keeping consistent sleep/wake times

Quitting smoking is one of the single best things you can do for your asthma and overall health, and it will also decrease reflux if you have GERD.

Reflux Medications

Along with lifestyle changes, your doctor may prescribe medication or recommend an over-the-counter medication for acid reflux. The results of studies looking at whether or not treating GERD with medication improves asthma symptoms are mixed, but there is some evidence that doing so may improve quality of life and be most helpful for those with nighttime symptoms of asthma and GERD.

If your physician suspects that your asthma is related to GERD, you will likely be prescribed an acid-suppressive medication for one to two months to see if asthma symptoms improve.

It's important to only take one type of medication for acid reflux or GERD a time. The types of medications include:

  • Antacids are OTC medications used for heartburn and acid indigestion that neutralize acids in the stomach. Common options include Maalox, Mylanta, Gelusil, Gaviscon, Rolaids, and Tums,
  • Pepto-Bismal (bismuth subsalicylate) includes a mineral (bismuth) with antacid and antidiarrheal effects. This OTC medication may increase fluid absorbed in the intestines and reduce levels of stomach acid.
  • H2-receptor blockers reduce levels of acid created in the stomach lining. Many are available in both OTC and prescription options, such as Pepcid (famotidine), Tagamet (cimetidine), and Zantac (ranitidine).
  • Proton pump inhibitors (PPIs) also reduce the amount of acid produced. They come in some OTC and prescription options, and their effects are increased when taken for several days. Options include Nexium (esomeprazole), Prevacid (lansoprazole), Prilosec (omeprazole), Dexilant (dexlansoprazole), Protonix (pantoprazole), and Aciphex (rabeprazole).

April 1, 2020 Update: The Food and Drug Administration (FDA) announced the recall of all medications containing the ingredient ranitidine, known by the brand name Zantac. The FDA also advised against taking OTC forms of ranitidine, and for patients taking prescription ranitidine to speak with their healthcare provider about other treatment options before stopping medication. For more information, visit the FDA's website.

H2-receptor blockers and proton pump inhibitors do not provide immediate relief like antacids but suppress acid production in the stomach for around 12 to 24 hours. These acid-suppressing medications, especially PPIs, are commonly used for those with GERD-related asthma. If asthma symptoms improve after a one- or two-month trial period on PPI, you may be prescribed the medication for an addition two months.

The exact cause of asthma is unknown and triggers for asthma vary from person to person. There is typically a strong reaction of the immune system that creates inflammation and narrowing of the airways. Although asthma can occur at any age, it typically develops in childhood.

If these medications are going to help your GERD, it is unlikely that any one will be more effective than the other. Likewise, if one medication in a class does not work, it is unlikely that another in that same class would be helpful. If your symptoms persist, your provider may refer you for further testing.

Asthma Medications

Medications prescribed for asthma vary based asthma severity and symptom triggers. Your doctor may weigh the pros and cons of certain asthma medications that may aggravate GERD. Although, side effects can vary by person and you may need to test different drugs to see which ones control asthma without worsening acid reflux.

The most commonly prescribed medications for asthma include:

  • Short-acting beta-agonists (SABAs), known as rescue inhalers, are fast-acting medications that can address acute symptoms by widening airways quickly. A SABA may be all that's needed for mild asthma or exercise-induced asthma that only happens during physical activity. 
  • An inhaled corticosteroid, long-term controller medication that is taken daily to reduce inflammation and prevent symptoms over time, especially in those with persistent asthma who experience symptoms several times a week to multiple times a day. These are not used for acute symptoms, but can improve symptoms over time.

Often, a combination of these is recommended.

Additional medications may be prescribed for allergic asthma or if asthma is poorly controlled even when medication is taken as prescribed. If you have GERD and asthma, your physician will likely avoid theophylline as an add-on treatment since it has been shown to stimulate gastric secretions and increase GERD symptoms by 170%.

Your physician may avoid or delay prescribing oral corticosteroids for severe asthma since high-dose corticosteroids may increase GERD and, in turn, exacerbate asthma. If you are prescribed oral corticosteroids, you may need careful monitoring.

If asthma symptoms become severe, it can cause respiratory distress and even lead to death, so adequate management is critical.

Talk to your doctor about all medications, supplements, and vitamins that you currently take. While some drugs pose minor interaction risks, others may outright contraindicate use or prompt careful consideration as to whether the pros of treatment outweigh the cons in your case.

Surgery

While not usually necessary, some patients with severe GERD may choose GERD surgery if medical treatment fails or they would rather not have to take medications for the rest of their life.

A common surgical procedure to treat chronic acid reflux is fundoplication, which involves sewing the top of your stomach around your lower esophagus and LES. This procedure adds pressure to the LES in an attempt to strengthen it reduce reflux. If your GERD and asthma are related to an issue with the LES or hiatal hernia, surgical fundoplication may be considered.

Acid Reflux Treatment
  • Antacids, proton pump inhibitors, or H2-receptor blockers

  • Avoidance/reduction of foods that can worsen symptoms

  • GERD surgery

Asthma Treatment
  • Asthma action plan

  • Fast-acting, short-term medications

  • Long-term controller medications

  • Avoidance/management of triggers, such as allergens

A Word From Verywell

It's important to consult a physician if you have symptoms of asthma and/or acid reflux, especially if they are occurring multiple times a week. Aside from the fact that one condition can influence the other, each poses other potential complications as well.

Both are common conditions with many treatment options to help relieve symptoms and prevent them from occurring. If you're already been diagnosed with asthma or acid reflux but experience a change or worsening of symptoms, consult your doctor. Your medications or asthma action plan may need to be adjusted.

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Article Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
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Additional Reading
  • National Heart, Lung, and Blood Institute. Expert Panel Report 3 (EPR3): Guidelines for the Diagnosis and Management of Asthma