Gastroesophageal reflux disease (GERD) is a common comorbidity for asthma sufferers, but many patients don’t make the connection that control of their asthma is tied to control of their GERD.
Many asthma sufferers have comorbid conditions that contribute to the control (or lack of control) of their asthma. Gastroesophageal reflux disease, or GERD, is frequently involved with asthma but many patients don’t make the connection that control of their asthma is tied to control of their GERD. There are a number of approaches to help these patients deal with GERD. This article will discuss the relationship of asthma and GERD and describe how treatment of the reflux helps dampen the asthma problem.
Asthma is described as: “A common chronic disorder of the airways that is complex and characterized by variable and recurring symptoms, airflow obstruction, bronchial hyperresponsiveness, and an underlying inflammation.”1 This description comes from the evidence-based guidelines produced by the National Institutes of Health (NIH) by way of the National Heart, Lung, and Blood Institute’s National Asthma Education and Prevention Program (NAEPP). The most recent release of guidelines from the NAEPP was released in 2007 and is called the Expert Panel Report 3 (EPR-3).1
Asthma symptoms vary from person-to-person and include wheezing, coughing, shortness of breath, and complaints of chest tightness, and the symptoms vary in intensity over time. Variations may occur with changing seasons, changing exposure to inhaled triggers (allergens and irritants), intense emotions, changing ambient temperature, nighttime, exercise; reactions to certain foods or medicines, and sometime asthma symptoms flare up with no apparent cause.
Changes in symptoms and the related increase in work of breathing can occur suddenly or appear over the course of a few hours. Relief may be spontaneous or may involve using an inhaled short-acting bronchodilator. More severe asthma may bring a step up in medications to include an inhaled corticosteroid on a daily basis to gain control of symptoms, or possibly a combination of a long-acting bronchodilator plus inhaled corticosteroid given daily with the short-acting bronchodilator available as a rescue medication.
The EPR-3 guidelines provide the framework for assessing the patient, gathering diagnostic and disease monitoring information to establish the diagnosis and follow its course, treatment options and strategies, patient and family education, and it addresses comorbid conditions. Treatment is based on severity and includes medications (classified as rescue or control), education, self-management, strategies to prevent exposure to triggers, and reduce problems caused by comorbid conditions. The list of comorbid conditions found in the EPR-3 includes sinusitis, rhinitis, psychiatric illness, allergic bronchopulmonary aspergillosis (ABPA), obstructive sleep apnea (OSA), chronic obstructive pulmonary disease (COPD) and GERD.
Gastroesophageal Reflux Disease
GERD is described as “a condition which develops when the reflux of stomach contents causes troublesome symptoms and/or complications.”2 This description comes from a published review of the condition referred to as the Montreal definition of GERD. Symptoms of GERD include heart burn (a retrosternal burning sensation) and regurgitation (a perception of the movement of gastric content into the hypopharynx or mouth). The Montreal definition considers the diagnosis of GERD to be present when symptoms are troublesome to the patient and when mild symptoms occur two or more days a week, or moderate to severe symptoms occur more than once a week. The major symptom of GERD is the complaint of epigastric pain.
GERD is associated with night-time disturbances of sleep which can be substantially reduced with treatment. GERD can also cause a narrowing of the esophagus (called reflux stricture) which brings about difficulty swallowing (dysphagia). Exercise may initiate symptoms of GERD and the pain associated with GERD may mimic the pain of a cardiac ischemic event. People who suffer from GERD often also have a chronic cough, chronic laryngitis, and asthma.2 With this brief review of GERD taken from the Montreal article, one can see that asthma and GERD have many common issues including the increase symptoms during the night, increase of symptoms related to exercise, the weekly occurrence of troublesome symptoms, and coughing.2 (Note that the EPR-3 guidelines refer to GERD some 13 times.1)
Besides assessing GERD from the symptoms, the disease may also be evaluated by placing a pH probe into the esophagus and checking for the drop in pH as gastric content flows backward. This approach usually requires the probe to be in place for 24 hours, and the condition is evaluated based on the frequency of reflux events, the period time that covers the drop in pH (exposure time) and the acid clearance time. When using a pH probe, a pH of less than four is often used as a threshold to define a reflux episode. (This level of monitoring is fairly uncomfortable and is not frequently utilized.) Another method for assessing GERD involves endoscopic examination of the esophageal mucosa. GERD can cause reflux esophagitis (also called erosive esophagitis) involving visible disruptions of the mucosal layer. Hiatal hernia is another link to GERD.3
Asthma and GERD
GERD affects all ages from adult to infant. In a systematic review article from 2010 in Pediatrics, the authors concluded that the prevalence of GERD in adult patients with asthma averages about 59.2% while in children with asthma the prevalence averages about 22.8%.4 The reflux symptoms are increasingly present as asthma severity increases. An Italian study published in 2000 found 30% of patients with mild asthma complained of reflux, while 46% of those with moderate asthma had issues with GERD, and 70% of severe asthmatics had the symptoms of reflux.5 Comparing people with GERD to those without, those with GERD have a significant risk of also having asthma—with some 50-80% of asthmatics overall complain of symptoms.6
It is unclear as to which disease comes first; the evidence is not strong enough to support GERD preceding asthma or to conclude that asthma brings about GERD. The Montreal definition states that GERD can be an “aggravating cofactor” as a way to describe the relationship between asthma and GERD.2-3 Many authors agree that the association of GERD and asthma may occur by way of several mechanisms. First, the reflux contents of the esophagus can be aspirated into the pulmonary tree bringing on damage by direct exposure to the acid. Second, the reflux in the esophagus may stimulate the vagus nerve causing cough and bronchospasm in the airways. Third, the bronchospasm of asthma may cause an increasing respiratory effort that increases the pressure gradient across the esophageal sphincter and increases the retrograde reflux of gastric content. Fourth, the medications taken to treat asthma may induce GERD.3,6,7 Another article describes the relationship between asthma and GERD as “a vicious cycle where asthma and medications used in asthma treatment may increase GERD and GERD may subsequently provoke asthma aymptoms.”6
Subsets and Special Considerations
Regarding the common complaint of cough that occurs in both asthma and GERD, the EPR-3 guidelines describe a form of asthma known as cough-variant asthma. This form of asthma tends to occur mostly in young children and the principle complaint (and often the only complaint) is a chronic cough. The diagnosis of cough variant asthma is confirmed by a positive response to asthma medication.1 OSA is often added to asthma and GERD as another comorbid condition. In the discussion of OSA/asthma/GERD, it is thought that OSA may promote GERD and thus make asthma worse by triggering bronchospasm through stimulation of the vagus nerve.6 OSA also causes a similar increase in the pressure gradient across the esophageal sphincter as described earlier in bronchospasm – resulting in an increased risk of having reflux occur as the patient tries to inspire against a blocked airway. Obesity is another special consideration that appears to increase asthma symptoms of its own accord and tends to increase the risk of GERD as well.8
Treatment of GERD
The EPR-3 guidelines makes the recommendation that GERD be treated in patients with asthma who frequently complain of heartburn – particularly in patients who suffer from increased asthma symptoms at night. The guidelines1 recommend four actions or strategies to help manage GERD including;
- Avoid heavy meals, fried food, caffeine, and alcohol;
- Refrain from eating or drinking within 3 hours of going to bed;
- Use 6- to 8-inch blocks under the bed frame at the head to elevate the head; and
- Use appropriate medications to control symptoms of GERD.
Medications to treat GERD fall into five major categories. The most commonly used category is the proton pump inhibiter (PPI) and includes such medications as omeprazole (Prilosec), lansoprazole (Prevacid), pantoproazole (Protonix), and esomeprazole (Nexium). PPI drugs decrease stomach acid production. The next category is prokinetics and includes bethanechol (Urecholine) and metoclopramide (Reglan). Prokinetics strengthen the lower esophageal sphincter and/or empty the stomach faster. H2 blocker is the next category and includes medications such as cimetidine (Tagament), famotidine (Pepcid), and ranitidine (Zantac). H2 blockers decrease stomach acid secretion by blocking histamine release.
The last category, antacids, also reduce symptoms from GERD. Many of these products include salts such as magnesium, calcium, and aluminum in combination with hydroxide or bicarbonate ions. These products neutralize stomach acid. They include brand names such as Alka-Seltzer, Maalox, Pepto-Bismol, Tums, Rolaids, or Mylanta.9 (Note that using high doses and prolonged use of proton pump inhibiter medications carries an increased risk of infection, bone fractures, and dementia.10)
Surgery is another option for treating GERD. It is usually reserved for the most severe cases that have not been successfully managed with the steps and medications mentioned above. The surgical procedure aims at reestablishing the function of the esophageal sphincter. When this treatment approach is used, research has shown improvement in asthma symptoms; 34% of patients became symptom free, 2% showed improvement in asthma symptoms, and 24% continued without improvement.11
Despite the reported success of surgery and the effectiveness of medications and other interventions in reducing symptoms of GERD, data is inconclusive in linking effective treatment of GERD to a reduction in asthma symptoms. Problems in the research methods may contribute to lack of strong, high-quality evidence.3,4,6 In a Cochrane review published in 2009, the researchers found that interventions used and assessment outcomes were not consistent and that data could not be combined into a meta-analysis. Moreover, they intended to look at the effect of GERD treatment in asthmatic adults and children but found a serious lack of studies that involved pediatric populations.12
Asthma and GERD are common comorbidities and the latest evidence-based guidelines (EPR-3) recommend that GERD should be treated in order to help reduce issues with asthma. However, the published studies so far have not been conclusive as to the impact of treatment. There may be a connection between controlling GERD to aid in asthma control but the high quality research to prove this is lacking. More robust research is required to establish or remove the link. Connections also tie asthma and GERD to OSA and to increased nighttime symptoms. Again, these connections are not clearly defined and although treatment in all of these areas tends to improve quality of life, the data showing what strategies work most effectively is missing. RT
Bill Pruitt, MBA, RRT, CPFT, AE-C, FAARC, is a senior instructor and director of clinical education in the department of Cardiorespiratory Sciences, College of Allied Health Sciences, at the University of South Alabama in Mobile. He has served a term as the President of the Association of Asthma Educators for 2016. For further information, contact [email protected]
The NAEPP EPR-3 Guidelines http://www.nhlbi.nih.gov/health-pro/guidelines/current/asthma-guidelines/summary-report-2007. Accessed 8/16/16.
Vakil, N., Van Zanten, S.V., Kahrilas, P., Dent, J. and Jones, R., 2006. The Montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus. The American Journal of Gastroenterology, 101(8): 1900-1920.
Havemann, BD, Henderson, CA, El?Serag, HB, 2007. The association between gastro?oesophageal reflux disease and asthma: a systematic review. Gut, 56(12): 1654–1664.
Thakkar, K., Boatright, R.O., Gilger, M.A. and El-Serag, H.B., 2010. Gastroesophageal reflux and asthma in children: a systematic review. Pediatrics, 125(4), pp.e925-e930.
Gatto, G., Peri, V., Cuttitta, G., Cibella, F., Gjomarkaj, M., et. al, 2000. Gastroesophageal reflux symptoms are more frequent in patients with severe asthma. Gastroenterology International, 13(4): 139-142.
Boulet, L.P. and Boulay, M.È., 2011. Asthma-related comorbidities. Expert Review of Respiratory Medicine, 5(3): 377-393.
Gibson, P.G., Henry, R. and Coughlan, J.J., 2003. Gastro?oesophageal reflux treatment for asthma in adults and children. The Cochrane Library.
Gibeon, D., Heaney, L.G., Brightling, C.E., Niven, R., Mansur, A.H., Chaudhuri, R., Bucknall, C.E. and Menzies-Gow, A.N., 2015. Dedicated severe asthma services improve health-care use and quality of life. CHEST Journal, 148(4), pp.870-876.
From the Lifescript websight on medications to treat GERD. http://www.lifescript.com/health/centers/heartburn_gerd/treatments/drugs.aspx. Accessed 8/20/16.
From Ask an Allergist: How GERD affects asthma. Found on the Allergy and Asthma Network website. http://www.allergyasthmanetwork.org/professionals/ Accessed 7/27/16.
Alkhayat, K. and Mohamed, A., 2015. Value of proton pump inhibitors therapy in patients having GERD concurrent with uncontrolled asthma. Egyptian Journal of Chest Diseases and Tuberculosis, 64(2), pp.483-487.
Gibson, P.G., Henry, R. and Coughlan, J.J., 2003. Gastro?oesophageal reflux treatment for asthma in adults and children. The Cochrane Library.