GERD and Asthma
By Kathleen A. Sheerin, MD, FAAAAI
June 2007
Nineteen million Americans, from infants to seniors, suffer from gastroesophageal reflux disease (GERD). If you have asthma, your chances of having GERD are higher than those without the condition. Studies show that as many as 70% of patients with asthma have GERD compared to 20%-30% of the general population.
What is GERD?
After you eat, a part of your digestive system called the lower esophageal sphincter usually remains closed as you digest your food. However, sometimes it relaxes on the job, allowing stomach acid to flow back, or reflux, into the esophagus.
Heartburn is the most common symptom caused by gastro esophageal reflux. Almost everyone has experienced heartburn at one time or another. Other symptoms that occur less frequently but can also indicate that you could have GERD are:
- Acid regurgitation (retasting your food after eating)
- Difficulty or pain when swallowing
- Sudden excess of saliva
- Chronic sore throat
- Laryngitis, hoarseness
- Inflammation of the gums
- Cavities
- Sour taste
- Bad breath
- Chest pain
- No symptoms at all ("silent reflux")
Although symptoms of GERD are common, often the condition is not diagnosed and symptoms go untreated. For patients with asthma, untreated reflux could mean uncontrolled asthma.
The airway connection
Why does GERD occur so frequently in patients with asthma? Changes in pressure in the chest that occur during airway obstruction in asthma can actually help to relax the sphincter at the bottom of the esophagus that controls the flow of stomach contents. The end result is that more negative pressure in the chest can cause stomach contents to flow up the esophagus rather than down. Acid in the esophagus can irritate the lungs either directly by aspiration into the lung or indirectly via stimulation of nerves. This can make the airways more irritable or hyperreactive to other triggers, like cold air, pollen, smoke, etc.
Although studies have shown a relationship between asthma and GERD, researchers are not certain of the exact interaction. Reflux may worsen asthma symptoms; on the other hand, asthma and some asthma medications, especially theophylline, may worsen reflux symptoms.
This cycle of reflux and airway obstruction may contribute to the development of progressively worsening asthma and other pulmonary disease. Severe, chronic and treatment-resistant asthma is more likely to be associated with GERD. Obesity, asthma and GERD are all interrelated. So if you are overweight you are more likely to have reflux and asthma as well.
Diagnosis is difficult
The lack of knowledge about the exact relationship between GERD and asthma can make it difficult for your doctor to decide on the right diagnosis and proper medication. Clues that may indicate the co-existence of the two conditions include:
- Increased asthma symptoms after meals or exercise;
- Night symptoms (initiated by lying down);
- Respiratory symptoms such as frequent coughing and hoarseness; and
- Recurrent pneumonia.
Physicians may use one or several tests to diagnose GERD, including esophageal pH monitoring, a specialized test that can actually determine if and how much you are refluxing; gastroesophageal scintiscanning; or upper gastrointestinal tract endoscopy. If the tests are positive and your physician diagnoses you with GERD, he or she will then work with you to establish the best treatment program. Your physician may also search for Helicobacter pylori, bacteria that thrive in the acid environment of the stomach. This bacterium has been implicated in GERD and peptic ulcer disease.
Treatment
In a review by Field and Sutherland (1), the authors showed that asthma symptoms improved in 69% of the subjects and asthma medication use was reduced in 62% of the subjects. Although final conclusive evidence that reflux therapy helps asthma is lacking, most physicians will aggressively treat reflux symptoms in their asthmatic patients. Treatment includes changes in lifestyle and mediation.
Lifestyle changes can include:
- Elevate the head of the bed 6-8 inches
- Lose weight
- Stop smoking
- Decrease alcohol intake
- Limit meal size and avoid heavy evening meals
- Do not lie down within two to three hours of eating
- Decrease caffeine intake
- Avoid theophylline (if possible)
Medications
There are three categories of medications available for treatment of reflux disease. Antacids and H2 blockers are widely available over the counter medication to decrease the effects of stomach acid. New medications called proton pump inhibitors block acid production.
A recent study by O'Connor (2) looked at the most cost effective way to diagnose and treat reflux in the patient with asthma. He suggests starting with a proton pump inhibitor for three months. If that is not effective in controlling symptoms, your doctor can order a pH probe. If your doctor finds reflux, he or she can then increase the medication until symptoms are controlled. Occasionally, if reflux is bad enough, surgery may help.
If you have asthma and GERD symptoms, see your physician for proper diagnosis and treatment.
- Field SK, SutherlandLR. Does antireflux therapy improve asthma in asthmatics with gastroesophageal rflux? Chest:1998;114;275-283
- O'Conner JF. The cost-effectiveness of strategies to assess gastroesophageal reflux as an exacerbating factor in asthma. AmJGastroenterol. 1999;94:1472-1480
Kathleen A. Sheerin, MD, FAAAAI, is a Fellow of the American Academy of Allergy, Asthma and Immunology (AAAAI) and a practicing allergist/immunologist in Atlanta, GA.
