Outpatient Management of GERD

Welcome back to Run the List, a medical education podcast and internal medicine. As a quick disclaimer, this podcast is made for educational and informational purposes only, and should not be understood as medical advice under any circumstances. I'm so glad to be back for our next episode on GERD. I really enjoyed recording our last episode in Naveen, and it's been so great to see how many listeners are still tuning in. Yeah, Emily was same on my end. I thought it was so fun to be back recording. It's always fun to talk about topics that are near and dear to my heart, such as GERD, and so I'm excited to pick up where we left off from our last episode. Me too. So let's refresh ourselves on our case. We have Mr. S who's a 52-year-old male who presents the primary care clinic with classic symptoms of GERD, though without any alarm features. Last episode we reviewed the list of dietary triggers for GERD, which is a nice transition to today's episode on treatment options. So Naveen, how do you approach treatment of GERD in the outpatient setting? So Emily, I like to think about having three different goals of treatment when I'm meeting with my patients. The first goal is to resolve their symptoms, and then as part of that goal, I also want to maintain remission of their symptoms once we achieve that resolution. So that's goal number one. Number two is that if there's a suffigitis or inflammation of the suffigus present, I want to heal that as suffigitis. And three, I want to manage and prevent complications of long-term GERD. To reach those three goals, the first step is always lifestyle modifications, and this applies to all patients, regardless of how severe their GERD symptoms may be. So within this bucket of lifestyle modifications, there's five different things I like to talk about. I like to counsel my patients on. The first is minimizing dietary triggers. We spent a good amount of time last episode talking about the various dietary influences on the lower esophageal sphincter, and how things like caffeine, chocolate, peppermint, alcohol, fatty foods, all lower the lower esophageal sphincter tone, and thereby allow reflux to occur. So I like to talk to my patients about trying to minimize exposure to those foods. Number two is allowing enough time between the last meal of the day and laying down for bed. For example, if you were to have dinner around six o'clock, we typically say to allow at least three hours between that last meal and when you lay down for bed. What that allows is for the stomach to completely empty before you put yourself in a position in which your laying flat and reflux can easily occur because you don't have gravity working in your favor. Now one way to counteract that speaks to the third lifestyle modification, which is to elevate the head of the bed by six inches. I know we talk a lot about this in primary care setting, but the key thing is it's not just propping up pillows because if you just prop yourself up with two or three pillows, that actually may not change the angle that you are trying to create of elevation between your stomach and thinking just moving up approximately into the soft gas. So the key is that you actually have to elevate the bed post and there's various ways of doing that. And now we actually have beds. You can actually adjust to create that proper incline. But if you're just elevating the bed post, we aim for six inches to help utilize gravity to keep gastric contents staying down and not refluxing upwards. Number four is weight loss, particularly for patients carrying excess weight centrally. If you recall, we were talking about various triggers of gird and another trigger is central obesity because there's this extrinsic external pressure on the stomach from excess central weight and that excess pressure actually pushes stomach contents up into the esophagus. So losing the weight centrally will help reduce that risk of reflux. And then lastly, smoking cessation is very helpful. Nicotine lowers the lower soft yield sphincter tone. And so removing the smoking exposure can actually do a great deal of good for patients who are having active gird symptoms. I'm sure your patients love coming to clinic and being told that they can no longer have alcohol, chocolate, chewing gum. They have to lose weight and now they also have to stop smoking. So generally we're telling patients start with lifestyle modifications, but I would imagine a lot of people end up needing additional help from medications. Is that right? Yeah, so it's such a good point you bring up because you so there's two types of patients. There are some patients who can actually do all of these things and yet they still have symptoms. And then there's a large group of patients as as you were alluding to who would rather not completely alter their lifestyle and are looking for a medication to help them with the reflux they're experiencing. So in addition to these lifestyle measures, which again, I'll always go over, but some patients won't be able to take take on all these changes. I then think about, okay, how are we going to approach starting an acid-suppressive regimen for a patient in my office who is presenting with reflux symptoms? So the way I think about it is I start with classifying the severity of their reflux. Now, if they are having mild and/or intermittent symptoms, so not every day and the symptoms are not too severe, then I like to use the approach of stepping up therapy. And what that means is that you start with a low dose histamine to receptor agnus, such as pepsid or femenodine, and you have your patients use that pepsid or femenodine as needed. Now, if their symptoms are persisting, increasing in frequency, then you can start that same pepsid or femenodine, but have them take it on a standing basis twice a day for four weeks. We counsel our patients to always take their acid medications half an hour to 60 minutes before the meal. Food will actually help activate these acid-suppressive agents, and so it's best to have the acid medication already on board before eating, and that will be more effective in terms of acid suppression and preventing symptoms from occurring. So after they've been on the H2 receptor antagonist for four weeks, I'll then have them update me with how they're feeling, and we will reassess the approach to treatment at that point. So if after four weeks they're on the pepsid or femenodine twice a day, they're taking it properly 30 minutes before each meal, and they're still not having their symptoms controlled, then we'll step up to a one-stayly proton pump inhibitor such as ameprosol. So that is for the group of patients who are having mild and are intermittent symptoms. Now, many times we'll meet patients who are having much more frequent and-or severe symptoms, or they've had an upper endoscopy already, and it demonstrated esophageitis. Those patients, I like to use the step-down approach, which is we'll actually start with the more intensive proton pump inhibitor, typically once a day. So common dosages, again, working with ameprosol will do 20 milligrams of ameprosol 30 to 60 minutes before the first meal of the day, and then have them do that for eight weeks. Now during that eight-week period, if they feel like they're having good controller symptoms during the day, but then they start having symptoms overnight, I'll suggest to them to add on a dose prior to dinner time, same timing, 30 to 60 minutes before that meal, and then again, update me after eight weeks of that treatment. Ideally, their symptoms will become controlled after this PPI therapy of eight weeks, and the important piece here, and we'll talk about this in a little bit, is that at that point, if they're well controlled, I'll try to taper them back down to an H2 receptor antagonist, like Pepsid, or promoting, except for patients who have a strong indication to remain on PPI, and those patients are the ones who have Baratisophagus or severe erosive esophageitis. Those patients really need to be on lifelong PPI therapy, where the benefits of the PPI outweigh the risks of the long-term side effects. So there's really two categories of patients, those with mild or intermittent symptoms, and in those you use a step-up approach, where you ramp up the therapy as needed, and then in the more severe cases, you're starting at a higher intensity of therapy and then tapering down as tolerated. So just on the topic of PPI, as I know, in my own practice, in internal medicine and also in rheumatology, we're a quite wary of long-term PPI's, we've heard of many side effects of long-term usage, and I've also heard of many patients trying to kind of self-taper off of PPI therapy. So can you tell us a little bit more about why that's important, even if the PPI is controlling their symptoms? Absolutely, such a great question. As you mentioned, Emily, we will find a lot of patients who are on long-term PPI therapy, and I think it's very important to revisit their current symptoms and try to assess if their symptoms are well-controlled, is this an opportunity to try to taper? And the reason why I think it's important is that we are learning there are many long-term side effects of using PPI's chronically. There is a lot of information and a lot of research out there. The three buckets that I've found are most clearly associated or causative of PPI's are the following. So there's the bucket of GI effects. There's a second bucket of malabsorption and the third bucket of kidney disease. I've found that these three areas have the most conclusive evidence that PPI use can lead to specific side effects. So within the GI bucket, we do know that PPI use can increase the risk of C-difcolitis, particularly when patients are traveling outside of the US. There is a higher risk in certain areas of acquiring travelers diarrhea or other interior confections. And that makes sense because with the absence of gastric acid to combat bacteria that's being transmitted orally, they're going to be at higher risk for those bacteria to find residents within their GI tract and cause those infections. We also know of the association between PPI use and microscopic colitis, which is a common cause of watery diarrhea and typically in more elderly population. So that is another side effect that we should be aware of especially if patients are coming with watery diarrhea. Could they be having microscopic colitis from PPI exposure? So that's bucket number one. Bucket number two is malabsorption. So within the malabsorptive category, there's four different things I think about. There's magnesium, calcium, B12, and iron. So gastric acid is required for absorption of all of these elements. And so when that proton pump is blocked by a PPI, these elements can be not absorbed at the same rate as they should be. Now, it doesn't happen in all patients. And so the current guidelines don't recommend screening for each of these levels to be checked. But if you have a patient who has any signs or symptoms of deficiency in any of these areas, magnesium, calcium, B12 or iron, certainly do have them checked and think, could this be coming from the PPI use? One thing I just want to mention about calcium is that for patients who are trying to preserve their bone health, but still need to be in a PPI, if they use calcium citrate, that is not pH dependent for absorption. So that's one way to ensure that they're still getting calcium, despite having a PPI on board and contrast that with calcium carbonate, which is the common green and tums, that calcium is not readily absorbed. So I always talk to patients about trying to use calcium citrate instead of carbonate for their bone health. And then lastly, within kidney disease, we do know there is a risk of albeit low having allergic interstitial nephritis or AIN from PPI use. So those are the three main buckets, GI effects, malabsorption and kidney disease, I think, of counseling my patients who are on long term PPI, and I'm trying to discuss with them why it's important for them to come off. So lots of good reasons to not be on this medication long term, as far as how to actually begin tapering, how do you start to counsel your patients? I think the main thing here is that you have to go slowly, and the reason for that is when you have a proton pump inhibitor that you've been taking long term, your body, your system has elevated levels of gastrin circulating, trying to stimulate the proton pumps to release acid, but of course they're being blocked by the PPI. So as soon as you remove the PPI, that serum gastrin is ready to stimulate all these proton pumps to create more acid. And so there's this absolute rebound effect that many patients will experience when they stop their PPI, that makes them feel like they cannot come off of a PPI ever. And it makes sense. If you're taking off a medication, you actually have worse symptoms than you ever had, even when you first started it. Of course, you'll think this is not something that can be stopped. Now, the key, though, is that you can counter these rebound effects by using an H2 receptor antagonist, like Pepsid or Fremotidine, on the days you're not taking the PPI. What I counsel my patients to do is that if they're on a once daily PPI, I say, okay, let's first try to just alternate every other day. So if you take it, you've been taking it every day, I'm going to have you take it on Monday, Wednesday, Friday, Sunday, and so on and so forth, where every other day you're taking a day off of the PPI. And on those off days, I have them take the Pepsid or Fremotidine twice a day to cover them from experiencing the rebound effect of the PPI withdrawal. So I do that for four weeks. This is a slow process. But if they are feeling well after four weeks on this alternating regimen, I then say, okay, let's now reduce the PPI to every three days and again use the H2 receptor antagonist on the off days for a two week trial. So the goal here is now we're on a PPI for every third day. And if they're still doing well after two weeks of this trial, I'll then say, okay, I think at this point, we can probably safely transition you to just the H2 receptor antagonist twice a day, exclusively. And that's a great goal. If you've gotten someone off of a PPI and their symptoms are still well controlled, and they're now on an H2 blocker, which has much less side effects because you still are producing some acid to counter all of those other effects we just mentioned. That's a great achievement. So once we're on to twice daily H2RA or subterant antagonist, I think that's already a huge win. Now if patients are motivated to try to come off of that, what I will do is have them try to go down to just once a day, dosing. So now they're just taking it half an hour before breakfast for an additional two to four weeks. If they're still well at that point, they can just exclusively use the Pepsidr for monodine as needed. The key point in addition to the fact that this has to be a slow process and you and you're protecting yourself from the rebound symptoms with the H2 blocker is that if at any point during the taper, they have recurrent symptoms, then you just go back to the last effective dose and restart from there. Sounds like there's a lot of opportunities to educate our patients on exactly the differences between the two different types of medication and how exactly to go about this tapering because it doesn't I think come naturally to a lot of patients. As we wrap up this case, just to sum up our case, we have Mr. S, who's 52-year-old gentleman presenting to primary care with classic symptoms of GERD, upon further history noting that his symptoms occur daily after meals, but they're pretty mild. And so we end up using a step-up approach therapy by starting him on femododine 20 milligrams twice daily before breakfast and dinner, with plans to follow up in four weeks to assess his response. Naveen, as we wrap up this case, can you just summarize the most important takeaways for our listeners? Absolutely, and Emily, thanks again. It's so fun to record with you because I'm remembering how good you are. It's summarizing the key details as we move through, so I love that. But let's do it one more time. So the three takeaways from today's podcast would be the following. So number one, remember to advise counsel all your patients on the lifestyle modifications that can be done to help counter GERD, and just to review that was minimizing dietary triggers, avoiding down for three hours after eating, elevating the head of bed by at least six inches, weight loss, especially if there's excess central obesity and then smoking cessation. Number two, remember the step-up versus step-down approach to therapy. If your patients are having intermittent or mild symptoms, you can apply the step-up approach, whereas if they're having frequent or end-or-severe symptoms or they had esophageitis on EGD, then you're going to use a step-down approach starting with a PPI. And then lastly, these PPI's, although they are quite good at controlling symptoms, they do have long-term side effects. So whenever someone you meet is having the GERD well controlled on a PPI, that is an opportunity to discuss tapering. And when you taper, go slowly. And on those days that you're having them not take the PPI, replace it with an H2 blocker, like Fumotidine, which will help counter the rebound effect of the PPI withdrawal. Great. So I think that wraps up our second episode on GERD treatment of GERD in the outpatient setting. We hope you guys enjoyed this episode, and we hope you'll join us again on the next episode when we finish up the topic of GERD with a discussion on the role of endoscopy, as well as pH monitoring for patients with this condition. Thank you so much, Navine, for all of your expertise. Thanks so much, Emily. Can't wait to do this one more time with our last installment on GERD. (bright music)