Anti-reflux and heartburn prescriptions

Medicare spending on anti reflux and heartburn prescriptions is enormous. A recent Wall Street Journal article reported that Nexium was the single most costly drug in terms of overall cost. At first glance the numbers are mindboggling.   There were 8,192,362 prescription claims for Nexium in 2013 for Medicare.Slide30 antacids

GERD and Proton Pump Inhibitors: Are PPI’s Safe?

GERD and Proton Pump Inhibitors

Proton pump inhibitors have become one of the most heavily prescribed types of medications in the United States. The names of these medications have become familiar even to people who don’t have reflux. Protonix, Nexium, Dexilant, Aciphex and others have become almost as familiar to folks as Pepsi and Coke.
The fact that they are so ubiquitous leads many patients and doctors to assume that they are harmless. Research in this area is beginning to lead many patients and physicians to re-think this assumption and the risk/benefit of long-term usage of these medications.

To be fair, these medications provide an enormous benefit to many patients. Their ability to block the production of acid in the stomach allows ulcers to heal and greatly reduces the symptoms of gastro-esophageal reflux or GERD. These medications make people feel better and they do not want to stop taking them because GERD symptoms rapidly return when the medications are stopped in about 80% of patients. Despite the fact that the FDA has advised that no more than three 14-day courses be used on any given patient in a one year period most people take them on a daily basis for years. Subsequently we are seeing unanticipated side effects.


Although many of the documented side effects are mild many patients are starting to question the wisdom of long-term use. Recent news has begun to highlight some of the more dramatic risk factors, particularly heightened cardiac risks. Some have suggested the increased risk of heart attack among PPI users is up to 21%.

Proton pump inhibitors may increase heart attack risk.
The New York Times (6/11, Bakalar) “Well” blog reports that research published in PLOS One suggests that “proton pump inhibitors…may increase the risk for heart attack.”
The Washington Post (6/11, Bernstein) “To Your Health” blog reports that “after combing through 16 million electronic records of 2.9 million patients in two separate databases,” investigators “found that people who take the medication to suppress the release of stomach acid are 16 percent to 21 percent more likely to” experience a heart attack. Nicholas J. Leeper, an author of the study, “said the Food and Drug Administration ‘should be aware of these findings,’ but agreed that only a large, prospective clinical study…could establish whether the drugs are actually causing more heart attacks.”
On its website, CBS News (6/11, Seidman) reports, however, that “analysis of patients using another type of antacid drugs called H2 blockers…did not show this increased risk.”

This is a tremendously important issue as PPI’s account for BILLIONS of health care dollars being spent every year just in the USA. They are often being taken in a manner that is contrary to FDA recommendations and they may be putting many patients at risk for problems they may not be aware of. I personally see patients every month who are seeking surgical control of their reflux so that they can avoid the possible consequences of long term PPI use.

Is GERD Causing Your Cough?

GERD, heartburn, hernia


Is GERD causing your cough?

There are many reasons one may have a cough and GERD could be one of them. “Coughing is a protective mechanism your body uses to clear the airway,” explains Dr. Kevin Gillian, MD at The Virginia Heartburn and Hernia Institute in Lorton, VA. But what causes a cough? It turns out that it could be a multitude of things ranging from allergies to acid reflux to GERD. It’s impossible to always pinpoint the cause of a cough by how it sounds and for a persistent cough; you should always visit your physician. However, there are some key differences in coughs that may give you clues as to what’s going on.

Postnasal drip

This can be either a wet or a dry cough. Mucus dripping down your throat (due to either allergies or a cold) tickles your nerve endings and triggers coughing.

Other symptoms of a cough caused by postnasal drip may include; increased coughing at night and a tickly feeling at the back of your throat. If postnasal drip is caused by allergies, itchy eyes and sneezing may accompany the coughing.

If you suspect your cough is being caused by allergies, an over-the-counter antihistamine may help. If your coughing is caused by a residual cold, natural remedies like saline washes and steam could help relieve congestion, If your symptoms do not improve in 7 -10 days, see your doctor to rule out a sinus infection, which might require antibiotics.


A dry cough that ends with a rattle or wheeze may be caused by asthma. Asthma is a condition that is marked by airway restriction. This can cause difficulty breathing as well as wheezing and coughing.

Other symptoms of a cough caused by asthma may include increased coughing at night and while exercising.

If you think you may have asthma, you will need to see your doctor for diagnosis and treatment of this potentially dangerous condition. If your doctor suspects that you have asthma, he will most likely order a spirometry, a lung function test. . There are two types of medications to treat asthma; quick-relief drugs (bronchodilators, which make it easier to breathe) and drugs you take daily to keep asthma under control.


A chronic, hacking cough that produces a lot of mucus, particularly in the morning may be indicative of COPD (chronic obstructive pulmonary disease). COPD includes chronic bronchitis and emphysema. The main cause of COPD is smoking.,

Other symptoms of COPD may include decreased coughing as the day progresses; shortness of breath, especially with physical activity; wheezing, fatigue, and chest tightness.

If your doctor suspects COPD, he will usually recommend lung function tests such as spirometry and a chest x-ray. The disease is treated with meds like bronchodilators and inhaled steroids. If diagnosed with COPD, it is imperative to stop smoking. In extreme cases, you may need oxygen therapy

Medication-related cough

A group of drugs known as ACE inhibitors are commonly prescribed to treat high blood pressure. In about 20% of patients, they can cause a dry cough. A medication related cough usually begins a few weeks after starting these medication..

If your ACE inhibitor is causing your cough, talk to your doctor. If your cough is mild, your doctor may switch you to a different ACE inhibitor. If the cough is severe, your doctor may want to switch you to another type of blood pressure medication entirely, such as an angiotensin receptor blocker or ARB.


GERD (gastroesophageal reflux disease) causes a dry, spasmodic cough. GERD characterized by acid from your stomach backing up into your esophagus. GERD is the second most common cause of chronic cough, causing about 40% of cases, according to a 2006 review published in Nature.

Symptoms of a cough caused by GERD include increased coughing when you’re lying down or eating. Approximately 75% of GERD patients that have a chronic cough caused by GERD have no other symptoms. However, if there are other symptoms present they usually include heartburn, hoarseness and globus ( lump in the throat sensation).. Normally heartburn is an innocuous condition. However, “if chronic heartburn is left untreated, it can lead to Barrett’s esophagus, which is a precursor to gastroesophageal cancer” says Dr. Gillian.

To determine if your cough is caused by GERD, your doctor may order an x-ray of the upper GI tract and/or an endoscopy. Coughing caused by GERD is often not fully controlled by medications and lifestyle adjustments. Minimally invasive laparoscopic operations ike the Nissen Fundoplicaion and LINX procedure control reflux and thus can stop the cough or significantly improve it.

The evaluation of chronic cough from GERD and the surgery to correct it is available at the Virginia Hernia and Heartburn Institute