Acid reflux may disrupt sleep, even without symptoms

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Chronic acid reflux may frequently wake people up at night, even when it doesn’t cause heartburn symptoms, a small study suggests.

The study, of 39 adults with gastroesophageal reflux disease (GERD) and nine GERD-free adults, found that those with the digestive disorder tended to wake up more often during the night—an average of three times per night, versus just under twice per night for their GERD-free counterparts.

Their sleep disruptions were often related to reflux episodes, as measured by a probe that was placed in the esophagus overnight.

Yet, the study found, most of the awakenings were not spurred by perceived heartburn symptoms; GERD patients reported sensing symptoms in only 16 percent of their sleep disruptions.

The findings, though based on a small group of patients, suggest that GERD may be contributing to poor sleep more often than has been suspected, said senior researcher Dr. Ronnie Fass, chief of gastroenterology at the Southern Arizona VA Health Care System in Tucson.

In an interview, Fass pointed out that when doctors evaluate patients for nighttime GERD problems, they typically ask about symptoms. However, the current findings suggest that “some wakings will be symptomatic, but many will not be,” he said.

Fass suggested that people with GERD tell their doctors if they are waking up frequently during the night, even if they do not feel that heartburn symptoms are the cause.

Then they might see whether gaining better control of the GERD improves their sleep, Fass said.

Some ways of managing GERD include weight loss, if needed; avoiding foods that spur symptoms and eating smaller, more frequent meals; and, for nighttime problems, raising the head of the bed 6 to 8 inches using wooden blocks under the bedposts.

Medications for symptom relief include antacids and acid-reducing drugs known as H2 blockers—such as ranitidine (Zantac) and cimetidine (Tagamet). Another class of drugs, known as proton-pump inhibitors (PPIs), can be prescribed to help prevent acid reflux episodes, particularly in people with more-severe GERD.

The current study, published in the journal Clinical Gastroenterology & Hepatology, was partly funded by Takeda Pharmaceuticals, which makes the PPI medication Prevacid. Fass serves as a consultant and researcher for the company.

The findings are based on 39 middle-aged adults with GERD who had been having at least three heartburn episodes per week for the previous three months, along with nine healthy adults.

All participants underwent overnight sleep monitoring, where a device worn on the wrist recorded their movements and a probe placed in the esophagus measured instances of acid reflux. Those on H2 blockers stopped using the medications at least three days prior to entering the study, and any PPI use was stopped at least three weeks beforehand.

Overall, the study found, 90 percent of GERD patients woke up at least once during overnight monitoring, with the majority of the awakenings (52 percent) being associated with an acid-reflux episode.

In the healthy comparison group, 78 percent woke up at least once, but never in relation to acid reflux.

Fass and his colleagues also found that in GERD patients, the reflux episodes usually came not before, but after they woke up. If the acid reflux usually happened after, and most awakenings were not accompanied by heartburn symptoms, it is not clear why GERD patients tended to wake up more often, according to the researchers.

One possibility, they say, is that nervous-system activity that helps stimulate acid reflux actually rouses people from sleep before the reflux occurs. Why these episodes would so often be symptom-free is also unclear, but one theory is that sleep reduces the sensitivity of the esophagus to stomach acid.

However, Fass and his colleagues note, some past studies have found that the large majority of acid reflux episodes seen in GERD, regardless of the time of day, may actually not trigger clear symptoms.

SOURCE: Clinical Gastroenterology & Hepatology, online May 31, 2010.

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