Dr. Keith Roach

DEAR DR. ROACH: I have had gastroesophageal reflux disease (GERD) for several years, but never paid much attention to it until the heartburn became annoying and almost permanent. My dentist had already said that the pockets in my tooth enamel were caused by acid reflux. So, in May, I went to see a gastroenterologist, and he immediately did an endoscopy, which showed I had grade 1 esophagitis.
He put me on 40 mg of omeprazole once a day and said he would do another endoscopy in four months to see if it healed. He also said I may be on omeprazole for life and that he has had patients taking it since 1986. I am concerned about the side effects and high dosage. It seems like I traded the heartburn for a frequently upset stomach.
Last week, I got a stomach infection that I never had before, and I assume it’s due to my lacking enough acid to kill bacteria. I am a 57-year-old man who does cardio and weightlifting at least five times a week, and is otherwise in good health. Should I get a second opinion? — N.U.
ANSWER: GERD is a common condition most people know. It’s the most common cause of heartburn. It’s caused by an ineffective muscular valve — the lower esophageal sphincter — that normally prevents acid from going backward into the esophagus (and even higher) where it doesn’t belong. Most people do not need medication treatment, as the symptoms are mild and intermittent.
Lifestyle changes — especially avoiding food late at night; raising the head of the bed; eliminating the most likely foods that exacerbate symptoms, such as caffeine-containing beverages and alcohol — can be effective for many. Occasional use of over-the-counter antacids or acid-suppressing drugs (H2 blockers like famotidine) is beneficial for many and has very little risk.
Other people continue to have symptoms, despite good adherence to the recommendations for lifestyle changes, and they do not get adequate relief from H2 blockers. In these cases, a course of a proton pump inhibitor, like omeprazole, is appropriate. I usually treat patients for six to eight weeks before tapering off the medicine.
When symptoms continue despite a course of PPIs, I refer patients to a gastroenterologist, who (like yours) usually performs an endoscopy. There are two concerns that tend to make me concur with your gastroenterologist: the damage to your teeth and the inflammation in the esophagus. These increase the likelihood that long-term use of a PPI may be necessary for symptom control.
This is prescribed under the assumption that you are doing all you can with the lifestyle changes. They really can make a big difference and keep you from needing to take these medicines, which have potential for side effects such as the bacterial infections you mentioned and others, including bone loss and low vitamin B12.
Finally, there are non-medication options, including surgery and endoscopic procedures that can address the reflux at the level of the valve. These are particularly important to consider in those who get adverse effects from PPIs.
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Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu or send mail to 628 Virginia Dr., Orlando, FL 32803.
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