Dr. Spechler noted that the latest medical treatments “are so good at stopping stomach acid that, by and large, what we used to call lifestyle modifications have really assumed a very secondary or even tertiary role. … Most of the [old] prohibitions—the dietary restrictions and things like that—were based more on ideas than on proof.” Thus for patients who have no worsening of symptoms after eating high-acid foods, “I'm very lenient on diet for patients with reflux disease.”
He added that physicians at his institution also advise patients to avoid eating meals close to bedtime and to avoid lying down immediately after eating.
Regarding the role of NSAIDs in heartburn or GERD, Dr. Spechler said that most studies have not shown NSAIDs to exacerbate these conditions but cautioned that that at least one has shown that these drugs may increase reflux. Thus “there are some concerns” about allowing patients with reflux to continue on NSAIDs.
“If the pills get stuck in the esophagus, they can be caustic; they can actually cause burns in the esophagus,” he explained. Moreover, “there has been an association of strictures with use of NSAIDs. But in general, we don't see major problems anymore. We're seeing fewer strictures. The medical treatments are so good that restricting [NSAIDs] has become a very secondary feature of care for the patient with reflux disease.”
He said that his institution will soon publish a study examining the effects of ibuprofen on reflux, in which the drug was associated with an increase in reflux among some patients.
“It did not show an enormous increase in acid reflux, but it did show a significant increase,” he said. However, “we don't know if that's ibuprofen specific or if that's [caused by] all NSAIDs.”
Dr. Orlando, however, indicated that he believes lifestyle modification is an integral part of long-term treatment. After putting the patient on an H2 antagonist or a proton pump inhibitor for 4–8 weeks, the problem usually subsides.
However, “if the patient hasn't adjusted their lifestyle, then I'll guarantee that those symptoms will come back again. So, in my mind, the medications are a crutch or a handle to capture the disease more efficiently, to get whatever damage may have been done to the lining of the stomach and the lining of the esophagus under control, and to remove what may be provocative things within the lifestyle—including diet—that may have contributed to the symptoms that you can control.”