How Gastroesophageal Reflux Disease (GERD) Is Treated

If you've been diagnosed with gastroesophageal reflux disease (GERD), your treatment plan may include lifestyle changes, over-the-counter medications, prescription medications, surgery, or a combination, depending on your situation. Assuming you don't have any complications from GERD or any esophageal problems, your doctor will probably recommend that you first try some of the more basic solutions before taking further steps.

Those with refractory GERD may require treatments that differ from the standard of care.

Home Remedies and Lifestyle

You may be able to control GERD or at least minimize acid reflux by implementing some lifestyle changes. Consider the following:

  • If you smoke, try to quit. There are many reasons smoking increases heartburn. Also, try to avoid secondhand smoke.
  • Work on losing weight if you're overweight or obese. Sometimes even losing 5 or 10 pounds can make a difference in your symptoms.
  • Don't eat foods that are known heartburn triggers. These include chocolate, citrus fruits and juices, tomatoes and tomato-based products, mustard, vinegar, mint products, and spicy, highly seasoned, fried, and fatty foods.
  • Avoid or at least minimize drinks containing caffeine (coffee, tea, cola) because these can relax the lower esophageal sphincter (LES).
  • Avoid or minimize alcohol, which relaxes the LES. 
  • Don't eat big meals. Eat several small meals throughout the day instead.
  • Eat your food slowly and chew it thoroughly.
  • Wait at least three hours after your last meal before going to bed, and make it a habit to avoid lying down for three hours after a meal.
  • Sleep with your head and shoulders propped up with a wedge pillow (regular ones won't work), or elevate the head of your bed 6 to 8 inches by putting blocks of wood under the bedposts. This will allow gravity to work for you and help keep your stomach acids where they should be—in your stomach, not your esophagus.
  • Wear clothes that are loose and comfortable. You need to avoid any tightness around your waist and stomach.
  • Sit upright in a comfortable chair rather than slouching.

Baking Soda
The main ingredient in baking soda is sodium bicarbonate, which your body naturally produces. You can use baking soda as a natural antacid to help settle the acid in your stomach and give you some relief from heartburn. Try dissolving 1/2 teaspoon in 4 ounces of water and sip it slowly. You should always talk to your doctor before using baking soda for reflux because it may interfere with your medications or increase your sodium levels. This is only a short-term solution; long-term use (or consuming more than the recommended amount of baking soda) may actually make your reflux worse.

Apple Cider Vinegar
While some people use apple cider vinegar to treat their heartburn, it's important to note that there haven't been any published clinical trials to support this. Fans of apple cider vinegar theorize that heartburn occurs because there isn't enough stomach acid, and taking apple cider vinegar brings the stomach acid level up, allowing your stomach to digest food properly and heartburn to subside. However, doctors recommend taking medications to reduce stomach acid and control acid reflux symptoms.

Taking undiluted apple cider vinegar could irritate your mouth and esophagus as it's very acidic. Undiluted, apple cider vinegar can also erode your tooth enamel. For these reasons, it's wise to dilute the vinegar with water if you plan to use it. Add from 1 to 3 teaspoons of vinegar to a cup of water.

Vinegar may interact with other medications that you're taking at the same time and instead of relieving heartburn, the vinegar may actually make it worse. If you're considering using apple cider vinegar as a treatment for heartburn, it's important that you talk to your doctor first.

Over-the-Counter Therapies

Many of the medications used for heartburn are available over the counter and by prescription.

Though the drugs are the same, OTC medications are available at a reduced dose, often one-half of their prescription counterparts. Your doctor may recommend over-the-counter medications for you if lifestyle changes haven't helped. Each medication works differently and you may need a combination of them to be effective. Be sure to talk to your doctor before starting any of these medications, as well as if your symptoms aren't getting better while taking them.

Antacids
Antacids like Mylanta and Maalox (aluminum hydroxide/magnesium hydroxide/simethicone), Rolaids (calcium carbonate and magnesium hydroxide), and Tums (calcium carbonate) are usually the first drugs recommended to relieve heartburn and other mild GERD symptoms. They each work to neutralize stomach acid. Side effects include constipation or diarrhea.

H2 Blockers
The parietal cells in your stomach lining are stimulated in a number of ways to produce acid. One of these acid stimulants is histamine, which binds to histamine 2 receptors on the parietal cell. H2 blockers, true to their name, block these receptor sites and therefore reduce acid production.

Tagamet HB (cimetidine), Pepcid AC (famotidine), Axid AR (nizatidine), and Zantac 75 (ranitidine) are all popular choices that are quite cost effective. They're also available in prescription strength.

Proton Pump Inhibitors (PPIs)
Your stomach produces acid to help break down food so it's easier to digest. In certain circumstances, this acid can irritate the lining of your stomach and duodenum (the upper part of your small intestine), causing issues such as ulcers.

Cells in the stomach make acid with enzymes called proton pumps. Proton pump inhibitors block the secretion of acid into the stomach by binding to these pumps. Decreasing the amount of stomach acid can help ulcers heal and reflux to subside. PPIs can also heal your esophageal lining. 

Proton pump inhibitors are more effective than H2 blockers. Because of this, they are more often used to treat chronic symptoms of heartburn. Like any drug, they can have side effects, but for most people, the amount of relief these drugs give far outweighs the potential drawbacks.

Some PPIs, such as Prilosec (omeprazole), Prevacid (lansoprazole), Nexium (esomeprazole), and Zegrid (omeprazole/sodium bicarbonate), are available over the counter.

PPIs are generally more expensive than H2 blockers, usually taken once daily 30 to 60 minutes prior to breakfast, and are taken for approximately eight weeks, at which point your doctor will re-evaluate how you are feeling. If your symptoms improve, your doctor may decrease your dose or even stop your medication. With a partial response, your doctor may increase your dose to twice a day. If you're still not getting relief for your GERD, your doctor will most likely refer you to a gastroenterologist or re-evaluate your diagnosis.

Comparing PPIs and H2 Blockers
Though both H2 blockers and proton pump inhibitors suppress gastric acid secretion, there are several ways in which these medications differ that will influence which is recommended for you.

 H2 BlockersPPIs
How Well They WorkH2 blockers effectively block histamine 2, but no other stimuli that lead to acid production.Proton pump inhibitors address several stimuli that contribute to acid production and are considered more effective than H2 blockers.
How Soon They WorkH2 blockers often work within an hour, becoming the most effective between one and three hours after you take them.PPIs work better when they're taken 30 minutes before your meal or on an empty stomach. When you wait to take them until right before or after you've eaten, your stomach has already released most of the acid the medicine is supposed to prevent.
How Long They LastH2 blockers may be effective for up to 12 hours. PPIs may last from 24 hours to three days.
Notable Side EffectsA headache is the most common side effect of H2 blocker use.Ongoing research is looking at the association between PPIs, reduced calcium absorption, and an increased risk of bone fractures.

Prescriptions

If lifestyle changes and/or over-the-counter medications aren't working to control your GERD symptoms, your doctor may put you on a stronger prescription medication.

The two most common options are PPIs and H2 blockers.

Proton Pump Inhibitors (PPIs)
The most common prescription drugs for GERD are proton pump inhibitors because they work so well to relieve symptoms in most people. Protonix (pantoprazole), Aciphex (rabeprazole), and Dexilant (dexlansoprazole), as well as the PPIs that are also available over-the-counter like Nexium, Prilosec, Prevacid, and Zegrid, are available by prescription.

H2 Blockers
Your doctor may prescribe a higher strength H2 blocker than you can get over-the-counter. These prescription-strength medications include Pepcid AC (famotidine), Axid AR (nizatidine), and Zantac 75 (ranitidine) and they are often cheaper than PPIs.

Other prescription options that may be considered include:

Prokinetics
Prokinetics work by making your stomach empty faster. These medications aren't used often and are typically prescribed to people who have refractory GERD (see below). Prokinetics can interact with other medications, so make sure you tell your doctor about everything you're taking, including over-the-counter drugs. Examples of prokinetics are Reglan (metoclopramide) and Urecholine (bethanechol). Side effects may include nausea, diarrhea, fatigue, depression, anxiety, and problems with movement.

Baclofen
Baclofen is another medication that doctors may use, especially for refractory GERD. It works by strengthening your lower esophageal sphincter (LES) and stopping it from relaxing so often. Baclofen can cause nausea and fatigue.

Surgeries

If your symptoms don't improve with lifestyle changes and medications, your doctor may consider surgery. This may also be a reasonable alternative to a lifetime of drugs and discomfort.

Fundoplication
A specific variation called Nissen fundoplication is the standard surgical treatment for GERD. The upper part of your stomach is wrapped around the lower esophageal sphincter (LES) to strengthen the sphincter and prevent acid reflux, as well as to repair a hiatal hernia.

This fundoplication procedure may be done using a laparoscope and requires only tiny incisions in the abdomen. To perform the fundoplication, surgeons use small instruments that hold a tiny camera. Laparoscopic fundoplication has been used safely and effectively in people of all ages, even babies. People can leave the hospital in one to three days and return to work in two to three weeks. This surgery is the most common type used for GERD and usually leads to good long-term control of related symptoms.

Endoscopic Techniques
Endoscopic techniques, performed using an endoscope, can help relieve GERD in a small number of people. One method is called endoscopic sewing, in which the surgeon puts stitches in the LES to create little pleats that help strengthen the muscle. Radiofrequency, in which the heat creates lesions that help your sphincter muscle tighten, is another endoscopic method that may be used.

LINX Device
This device, made up of a ring of magnetic beads, is wrapped around the area where your stomach and lower esophagus meet. The magnetic attraction of the beads keeps your LES closed, preventing reflux. It allows your LES to open, however, when you swallow, vomit, or burp. The advantages of the LINX system are that it's removable, tolerated well, and it's less invasive than a fundoplication.

Complementary Medicine (CAM)

In addition to traditional treatments, you can talk to your doctor about trying complementary alternative medicine (CAM) to help relieve your symptoms, though the scientific evidence is scant for most of these methods.

Melatonin
Studies have found that melatonin, found in the stomach and intestines, is extremely effective in treating GERD symptoms. One study found that the melatonin levels in people with GERD and ulcers were lower than that of healthy people. Melatonin may work to help strengthen the LES, decreasing acid reflux. It may be especially effective when it's combined with regular medications for GERD. Melatonin is safe as long as you take it at low doses and it can be used long-term with few if any, side effects.

Acupuncture
Several studies on treating GERD with acupuncture have shown that it can be effective in relieving symptoms. This seems to be especially true for electroacupuncture, which is when an electric current is used along with the needles. Since acupuncture is relatively safe, it might be worth exploring with your doctor's go-ahead.

Relaxation
Relaxation therapies can help improve your GERD symptoms by alleviating stress since too much tension can make your symptoms worse. Types of therapies you can explore include guided imagery, meditation, yoga, massage, deep breathing, and progressive muscle relaxation.

Hypnotherapy
Studies are limited, but hypnotherapy may be helpful in alleviating symptoms of GERD. Hypnotherapy also relieves anxiety and improves quality of life.

Herbal Remedies
There is little scientific evidence that herbal remedies treat GERD symptoms, but there are herbs that people say help relieve their acid reflux. Licorice root is one that studies have shown helps alleviate acid reflux. You can also try chamomile (avoid if you have a ragweed allergy), ginger, and marshmallow root.

Special Situations

Some patients continue to have symptoms of GERD despite a standard treatment with proton pump inhibitors. They have what is known as refractory gastroesophageal reflux disease (refractory GERD). Patients who experience refractory GERD usually fall into one of two groups: Those who need more aggressive treatment, and those who have other causes of their reflux symptoms.

Needing more aggressive treatment doesn't mean that your only option is surgery. In fact, those who have the best outcomes from anti-reflux surgery are those who previously responded to medications. Refractory patients don't typically respond as well to anti-reflux surgery. This, however, doesn't mean surgery, such as fundoplication, wouldn't be an option. Your doctor will weigh the possible risks and complications of the surgery against the possible benefits and discuss with you whether surgery is a good option.

Some patients don't respond as well to the traditional doses of PPIs, and a physician may consider increasing the dose, as well as having patients go to twice daily doses instead of the typical once a day dosing. Taking an H2 blocker before bedtime has been shown to help with symptoms too.

Physicians may also prescribe Baclofen or a prokinetic, such as Reglan, before meals and before bedtime to help decrease the risk of acid reflux.

Refractory GERD is rare. If you experience continued reflux symptoms despite treatment, you should talk to your doctor. Discussing the type of symptoms experienced, their frequency, and keeping track of possible reflux triggers will help you and your doctor finds an appropriate treatment plan.

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