This transcript has been edited for clarity.
Matthew F. Watto, MD: I'm Dr Matthew Watto. This is the Curbsiders. We are going to be talking about a very interesting topic. Stuart, did you want to tell them what this interview was about?
Stuart K. Brigham, MD: The interview was with Dr Amy Oxentenko about gastroesophageal reflux disease (GERD) and dyspepsia. In this short video, we are going to talk about our favorite piece of practice-changing knowledge and chew on it for just a little bit.
Paul N. Williams, MD: There were a lot of great clinical pearls in this episode. What I want to discuss are the things that we do that are not helpful. Often there is a lot of counseling about foods to avoid, and really, the evidence is against doing that. If patients identify specific food triggers for their symptoms, then great. Don't eat that stuff. But in terms of making blanket statements about foods that trigger heartburn symptoms, that counseling tends to not be useful.
Watto: For those keeping score at home, you can continue to drink coffee and eat tomatoes, pizza, chocolate, and spicy foods—all the things that people like.
Brigham: Wasn't there something about smoking and alcohol too?
Williams: Right. Please go ahead and continue to smoke and drink. No, in terms of stopping smoking and alcohol to improve GERD symptoms, the evidence is not really there. Obviously, for better health overall, counsel your patients to cease smoking and limit their alcohol intake. In terms of correcting their GERD, however, quitting those things may not be all that helpful.
Watto: Talking about safety, there was a recent randomized trial by Moayyedi and colleagues in Gastroenterology, looking at proton pump inhibitor (PPI) therapy for patients on rivaroxaban and aspirin. Many things had been in the news about PPIs from randomized controlled trials—for example, increasing infections like C difficile and pneumonia, osteoporosis, fractures, and dementia, etc. Over a 3-year median follow-up period, this cohort had no safety signals for those problems. The point that Dr Oxentenko made was, "I still talk to patients about these things. I want patients to know that these are very weak signals from observational studies, but there may be something there, so you still need to have the conversation."
Brigham: Patients in the RE-LY trial had reduced absorption of dabigatran, but that's because dabigatran is pH dependent. If you increase the pH of the stomach, that will decrease the absorption of dabigatran because of carboxylic acid.
Watto: One last point that I wanted to make. We asked about Barret's esophagus and who you might think about screening for this. People with longstanding GERD (more than 5 years) and the risk factors in addition to GERD are white male, obesity, older age, family history of gastroesophageal or gastrointestinal cancer, or a history of smoking. Those are patients in whom you might perform an index endoscopy. If you don't see any endoscopic evidence, you can stop there. If you biopsy and find metaplasia or dysplasia, they get plugged into a pathway and it gets a little more complicated from there.
Brigham: Before I give my pearl, I just want to tell the audience that Matt put in my script for "pearls" that "Stuart loves himself."
Watto: That's because you mentioned that your favorite pearl was the one where [Dr Oxentenko] agreed with your current practice. It's a great pearl, so tell us.
Brigham: It was about tapering PPI therapy. What a lot of us do may not be entirely evidence-based but it seems to work quite well. When you are tapering a patient off of a PPI, you can start by reducing the dosage, and then dosing every other day for a week or two, then every third day. Ultimately you taper off completely. Many patients (myself included) who just abruptly stop a PPI have significant rebound symptoms, and this can make it very difficult to come off of PPI therapy.
Watto: Does anyone else want to admit to trying this?
Williams: I stopped a PPI after years, and the symptoms were awful—worse than what you are trying to treat in the first place. The tapering approach works much better.
Watto: If all of this sounds great, please click on the link to the full podcast on GERD and dyspepsia. We have show notes, and you can join our mailing list and get those sent to your inbox for free. Our full discussion with Dr Oxentenko is available and there's lots more to enjoy. Thank you for watching.
The Curbsiders is a national network of students, residents, and clinician educators from across the country, representing 15 different institutions. They "curbside" experts to deconstruct various topics in the world of medicine to provide listeners with clinical pearls, practice-changing knowledge, and bad puns. Learn more about their contributors and follow them on Twitter.
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Cite this: Matthew F. Watto, Paul N. Williams, Stuart K. Brigham. GERD: What's Not Helpful and Other Practice Pearls - Medscape - Feb 07, 2020.