One of the most common gastrointestinal tract disorders (GI) is Gastroesophageal Reflux Disease, commonly referred to as GERD. This condition affects 20% of Americans. However, this statistic may be an underestimation. Over-the-counter antacid medications are widely available. But, recently, headlines have highlighted the risk factors associated with GERD medications.

Medication may undoubtedly have a time and place for appropriate use. However, it is estimated that up to 40% of people using the standard treatment for GERD still exhibit symptoms, leading us to believe that alternative approaches may be warranted.

This article will focus on common GERD medications, risks, and a functional medicine approach to GERD treatment for those looking to get off GERD medications.

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What is GERD?

GERD is a condition that occurs when stomach acid flows up into the esophagus. GERD has three subdivisions:

• Non-erosive reflux disease (NERD), which accounts for 60% of GERD cases, where there is no damage to the esophageal lining  
• Erosive esophagitis (EE), which accounts for 30% of GERD cases, where there is damage to the esophageal lining
• Barrett's esophagitis (BE) accounts for about 10% of GERD cases. This type of GERD is chronic and causes changes to the cells in the esophagus, increasing the risk of esophageal cancer.

What Causes GERD?

For most people, there is no single cause of GERD. Instead, it is a multifactorial disease encompassing several causes.

The lower esophageal sphincter (LES) functions as a door at the end of the esophagus, opening into the stomach. The LES should only open in response to pressure from food entering the esophagus. In GERD, the LES randomly opens when food is not present, allowing stomach acid to flow into the esophagus.

A hiatal hernia occurs when part of the stomach pushes through the opening of the diaphragm. This opening is the same opening that the esophagus runs through. Hiatal hernias reduce the integrity of the LES, allowing for acid to move into the esophagus. Hiatal hernias affect an astounding 94% of those with GERD.

Usually, stomach acid that moves into the esophagus is neutralized by salivary bicarbonate and moved back into the stomach through a wave-like movement called peristalsis. However, about 21% of those with GERD have impaired esophageal peristalsis.  

A layer of mucus lines the esophagus, or mucosa, which protects it from various substances it may encounter, acid being one of them. In GERD, researchers believe that the mucosa is damaged, making the esophagus more susceptible to acid damage.

The following will increase the risk of GERD:

• Consumption of fatty, fried, and spicy foods
• Eating late at night and eating large meals
• Alcohol and coffee consumption
• Obesity
• Certain medications, such as Motrin and Asprin
• Smoking
• Pregnancy
• Hormonal imbalances
• Low stomach acid (hypochlorhydria)
• Delayed stomach emptying (gastroparesis)
• Stress

Symptoms of GERD

Common GERD symptoms include:

• Heartburn
• Regurgitation or burping up fluid or food
• Burping without fluid or food
• Difficulty swallowing
• Painful swallowing
• Nausea
• Upper abdominal pain

The following symptoms may occur, although they are not as common:

• Asthma
• Chronic cough
• Chest pain
• Dental erosions
• Hoarse voice
• Trouble speaking
• A feeling of a lump in the throat

Top GERD Medications and Risk

The American College of Gastroenterology guidelines recommends starting patients with GERD on a once-a-day dose of a Proton Pump Inhibitor (PPI). If that fails to eliminate symptoms, twice-a-day dosing and/or changing the timing of dosing is recommended. Nighttime Histamine type 2 Receptor Antagonist (H2RA) therapy will be initiated if symptoms still occur. Prokinetic therapy is the last option and is not often used. Unfortunately GERD medications do come with many side effects and these should be discussed.

Proton Pump Inhibitors (PPIs)

Proton pump inhibitors (PPIs) inhibit the final step in gastric acid secretion by the parietal cells in the stomach, reducing stomach acid production. PPIs go by the names omeprazole, lansoprazole, esomeprazole, pantoprazole, dexlansoprazole, and rabeprazole.

Side effects are not typical when used at an appropriate dose for a short duration (two weeks). However, 25% of people who take PPIs will continue to use them for a year or longer. The longer the use, the more likely a side effect will occur and may include the following:

• Headaches, increased risk of dementia and hepatic encephalopathy
• Increased risk of stroke and myocardial infarction (heart attack)
• Nausea, vomiting, abdominal pain, constipation
• Increased risk of infections such as C.diff, Campylobacter, Salmonella
• B12 deficiency, iron deficiency, calcium deficiency, low magnesium
• Increased risk of osteoporosis, muscle pain, hip fracture
• Increased risk of hepatocellular carcinoma (cancer)
• Increased risk of acute kidney injury or chronic kidney disease
• Increased risk of COVID-19 infection or pneumonia

Histamine Receptor Antagonists (H2RA)

Histamine receptor antagonists (H2RA) are another class of medications. The parietal cells in the stomach are responsible for acid secretion, and on the surface of these cells are histamine receptors. Activation of type 1 histamine receptors will result in allergy-like symptoms. Activation of type 2 histamine receptors influences acid secretion, specifically nighttime secretion and acid secretion between meals. H2RAs will bind to and block the histamine type 2 receptor, suppressing about 70% of acid secretion. Common H2RAs include famotidine, cimetidine, ranitidine (currently recalled), and nizatidine (currently recalled). Side Effects of H2RAs include:

• Diarrhea
• Constipation
• Fatigue
• Muscle aches
• Headaches

Prokinetics

Prokinetic drugs target various biochemical pathways to induce gastrointestinal movement. However, these drugs are rarely used because of their effects on the central nervous and cardiovascular systems. Common prokinetic drugs include metoclopramide and domperidone. Side effects of prokinetics are:

• Abdominal pain
• nausea/vomiting
• Diarrhea
• Depression
• Blurred vision
• Tardive dyskinesia- involuntary, repetitive body movements
• Arrhythmias (irregular heartbeats)

Functional Medicine Labs to Test for Root Cause of GERD

To assess the root cause of GERD, one must consider both the multifactor causes and risk factors. Based on this, the following labs may be indicated:

Gastrointestinal testing:

GI testing, via the GI-MAP test, will assess the microbiome, a collective group of microbes in the large intestine that affects numerous body systems, including digestion and absorption, and may play a role in the development of GERD. This test also shows other markers of digestion and absorption. Since GERD is a GI condition that affects digestion and absorption, GI testing is warranted.

Hormone testing:

The female hormones estrogen and progesterone can also play a role in developing GERD. The DUTCH Complete hormone test checks for these hormones' surpluses, deficiencies, and imbalances.

Adrenal Testing:

Stress can also influence GERD. Salivary testing to check adrenal markers throughout the day via the Adrenocortex Stress Profile may help assess the stress response. This information can be helpful for a more individualized approach to the treatment of GERD.

Functional Medicine Treatment for GERD

Nutrition

Dietary factors can play a significant role in the production of GERD. Foods and beverages such as fried, fatty, spicy, and sour foods, tomatoes and tomato products, chocolate, orange and grapefruit juice, coffee, alcohol, and carbonated beverages can all trigger GERD symptoms. A diet diary, where all consumed food and drinks are written down, can be a helpful tool to monitor the intake of the above food and beverages to see an individual's specific triggers.

In addition to what the person is eating, the timing of food intake can also affect GERD symptoms. Irregular meal frequency, large meals, and eating before bedtime can also trigger GERD.  

Complementary and Alternative Medicine

Probiotics are supplements made of various beneficial microbes found as a normal part of the microbiome. A review of 12 studies showed that probiotics could help reduce GERD symptoms such as heartburn, nausea, burping, and more.

Magnesium is a mineral widely used in biochemical processes in the body. It is also one of the nutrients that may be depleted by using PPIs. A study in breastfed and formula-fed infants with GERD given magnesium showed that magnesium reduced symptoms in both groups. In addition, magnesium plays a role in estrogen metabolism and thus may affect hormone balancing, which contributes to GERD. Magnesium has even been added to PPIs, as several studies have shown additional benefits.

Breathing exercises are often recommended for stress reduction, and stress may play a role in GERD symptoms. A meta-analysis of over 200 patients found that breathing exercises can strengthen the LES and reduce GERD symptoms.

‍Summary

Gastrointestinal Reflux Disorder is a condition that affects many people. Standard medical treatments can be effective for some but come with many side effects, especially when taken longer than the recommended dose duration. Functional medicine testing can help to get to the root cause and aid in formulating a treatment plan to relieve GERD symptoms.