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Night Pains: Is Heartburn Keeping You Up?

Posted Aug 24 2008 1:49pm
DAVID R. MARKS, MD: Hi, and welcome to our webcast. I'm Dr. David Marks.

Heartburn can be a nuisance at any time of the day. But for many people, the greatest frustration happens at night. Not only can heartburn get in the way of a good night's sleep, but going to bed can actually make your heartburn worse, even if you're on medication.

Now, joining me to talk about nighttime heartburn and what you can do about are two experts. First is Dr. Jim Freston from the University of Connecticut, welcome.


DAVID R. MARKS, MD: And next to him is Dr. Michael Wolfe, and he is from Boston University School of Medicine. Welcome.


DAVID R. MARKS, MD: How big a problem is this?

MICHAEL WOLFE, MD: It's actually more of a problem than previously recognized. We used to think of heartburn as occurring only after meals. And, actually, in many situations, was more bothersome at night than during the daytime.

DAVID R. MARKS, MD: What is it that happens, that cause the pain?

JAMES FRESTON, MD, PhD: Well, acid coming up into the esophagus -- where acid doesn't belong -- is what causes the pain. When one is lying down at night, one doesn't have gravity to pull the acid back down in the stomach, like if you were upright.

The other thing is, when one is asleep, there is less swallowing. Swallowing clears the esophagus of acid, and also saliva helps neutralize the acid.

MICHAEL WOLFE, MD: A natural antacid. Saliva has --


MICHAEL WOLFE, MD: -- has bicarbonate inside it.

DAVID R. MARKS, MD: And it's free.


DAVID R. MARKS, MD: Now, we all think that medication -- medication does work very well for heartburn. And we probably think that it helps us all the time. But, in some cases, at night, it -- you get some breakthrough. How -- is that a common situation.

MICHAEL WOLFE, MD: Well, the classic example are the proton pump inhibitors. They're wonderful medication, and most people actually do get by by taking one pill a day in the morning. But there's significant number of people who actually will breakthrough at night. So-called "nocturnal acid breakthrough." And it'll occur right in the middle of the night, when someone is sound asleep. Not a good way to start the next day.

DAVID R. MARKS, MD: But if these medications are turning off the acid production, how is there acid that's actually there to get through?

JAMES FRESTON, MD, PhD: Well, in the case of the proton pump inhibitors that Michael just mentioned, they're taken in the morning. And their effect gradually does wear off. But then, as their effect is wearing off, remember now the patient is recumbent. Or the person is recumbent. And those factors I had mentioned earlier, that drive heartburn, kick in. They're not operating necessarily during the day.

DAVID R. MARKS, MD: So what should a person do?

MICHAEL WOLFE, MD: Well, there's several different maneuvers one can take to avoid --

DAVID R. MARKS, MD: Besides staying up all night, right?

MICHAEL WOLFE, MD: Oh, staying up all night is one way, but -- we can actually sleep with the entire head of the bed elevated, on bricks. That's great for the patient, but for the person sleeping with the patient, it's not too cool sometimes. So they have to stay awake and sleep elevated like that.

There are certain wedges one can use to raise the entire thorax -- not just the head of the bed with pillows, but rather from the waist up.

But the best thing to do is take a medication if you wake up in the middle of the night. The options include taking an antacid. Antacids will work very quickly. The problem is it's very possible the person will wake up again because the heartburn recurs.

An H2 blocker can be taken, and they will work eventually. But an hour will pass before the person actually is able to fall back asleep.

Or the third option is to take a combination of the two. Which will provide the quick relief of the antacid and the sustained relief of the H2 blocker. That, in many ways, is an ideal medication to take if one is going to experience, unfortunately experience, the breakthrough of heartburn in the middle of the night.

DAVID R. MARKS, MD: If a person has frequent symptoms, would you suggest that they take that preventively every night, before going to bed?

MICHAEL WOLFE, MD: The problem with that is that if we take it every night, the H2 blocker's at high enough dose, will actually lose their effect. We develop what's called a tolerance to the medication. They're best suited for taking on an intermittent basis.

DAVID R. MARKS, MD: Should people try to set a certain period of time between their dinner and their bedtime, does that help?

JAMES FRESTON, MD, PhD: Yes, indeed it does. Give yourself two hours. At least. If you've taken a very heavy or large meal, even more.

DAVID R. MARKS, MD: What about people who like to maybe have a drink of alcohol or wine at night, does that make the problem better or worse?

JAMES FRESTON, MD, PhD: It makes it worse. Those are the patients, or the people, I think who ought to be taking the --


JAMES FRESTON, MD, PhD: -- the antacid, especially the combination. Plan on taking it on that evening before the fire starts.

DAVID R. MARKS, MD: And smoking. That's an, also, another potential problem.

MICHAEL WOLFE, MD: Probably many mechanisms. The exact way smoking causes problems, it's not really clear. But it's very easy to tell a person not to smoke, because there's many other problems associated with smoking. Heartburn's just one of them.

DAVID R. MARKS, MD: Sure. Are there certain foods that should -- people should avoid? Maybe -- even if they give that two hours. Are there -- people always talk about spicy foods, hot foods. Is this a myth? Or, should people avoid these things?

JAMES FRESTON, MD, PhD: It's largely a myth that spicy foods and hot foods cause heartburn. They may cause discomfort down in the abdomen. We call that a different condition, dyspepsia.

Heartburn itself is commonly provoked by fatty foods, citrus, chocolate and lots of coffee. And a few other things.

DAVID R. MARKS, MD: So those are the things --

JAMES FRESTON, MD, PhD: But those are the major offenders.

DAVID R. MARKS, MD: -- to be avoided. At least late.


DAVID R. MARKS, MD: Now there is some research comparing different medications for nighttime breakthrough heartburn. Can you just summarize that research for us?

MICHAEL WOLFE, MD: To date, looking at nocturnal acid breakthrough, there's not really much of a difference with the medication, as far as the proton pump inhibitors. There are certain individual preferences from person-to-person, but they all pretty much act the same way as far as lasting through the night.

But if one breaks through, it really is going to vary on what one takes. Now, the medication that's now available -- the combination of the H2 blocker/antacid, Pepcid Complete -- hasn't really been studied enough to see if it's preferred over, for example, proton pump inhibitor. But it certainly makes a lot of sense to use something like that on an as-needed basis, if one breaks through. Or as Jim mentioned, if you know you're going to break through, take the H2 blocker before you go to bed. Don't take the chance.

DAVID R. MARKS, MD: Okay. Thank you both for joining us. Thank you for joining our webcast. I'm Dr. David Marks, goodbye.

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