Screen Sleep Disorder Patients for GI Reflux : Treating gastrointestinal reflux can improve sleep—and treating sleep disorders can improve reflux.

SCOTTSDALE, ARIZ. — Patients with sleep disorders should be screened for gastrointestinal reflux, Dr. Susan M. Harding advised at a meeting on sleep medicine sponsored by the American College of Chest Physicians.

Heartburn is common in patients with sleep complaints and can make their sleep problems worse, according to Dr. Harding, a professor of medicine and medical director of the Sleep/Wake Disorders Center at the University of Alabama, Birmingham.

It has not been shown to cause sleep disorders, or vice versa, she said. Nonetheless, researchers have demonstrated that treating gastrointestinal reflux can improve sleep—and that treating sleep disorders can improve reflux.

In one study cited by Dr. Harding, 62% of obstructive sleep apnea patients had symptoms of nighttime reflux. The patients who were compliant with continuous positive airway pressure therapy reduced their symptoms by 48%. Noncompliant patients had no improvement (Arch. Intern. Med. 2003;163:41–5).

Conversely, Dr. Harding cited a trial that enrolled 650 reflux patients with sleep complaints. Four weeks of treatment with a proton pump inhibitor significantly reduced sleep disturbances and improved sleep quality (Am. J. Gastroenterol. 2005;100:1914–22).

“Nighttime reflux is common in heartburn patients,” she said. “It causes sleep difficulties, and it is inadequately treated.”

Stable sleep protects against reflux, according to Dr. Harding. Esophageal acid take much longer to clear during sleep, and people swallow less often. Acid clearance mostly occurs during arousals.

“Is there an association between sleep-related reflux and obstructive sleep apnea?” she asked rhetorically. “Maybe. Maybe not.”

Despite identifying reflux in many obstructive sleep apnea patients, Dr. Harding noted that studies have failed to find a causal relationship or correlations among reflux scores, apnea severity, and other variables by which the two conditions are measured.

The conditions coexist in many patients, she said, which suggests that the relationship may be complex. “Reflux is not caused by obstructive sleep apnea, but reflux may be facilitated by obstructive sleep apnea,” she said, and called for more studies examining transient lower esophageal sphincter relaxations in obstructive sleep apnea patients.

Reflux should be considered whenever a patient presents with insomnia or excessive daytime sleepiness, according to Dr. Harding. Patients with erosive esophagitis are prone to sleep disturbances, she said, and nocturnal reflux has been shown to trigger respiratory symptoms in asthma patients. Sleep-related laryngospasm also can be triggered by reflux.

Consider doing esophageal pH monitoring along with polysomnography, Dr. Harding advised. If sleep-related reflux is diagnosed, urge patients to make the following lifestyle modifications (Arch. Intern. Med. 2006;166:965–71):

▸ Not eating for 2 hours before bedtime.

▸ Raising the head of the bed by about 6 inches using stacked bricks or a wedge.

▸ Avoiding certain foods (fats, caffeine, tomato products, sodas, and so forth).

▸ Avoiding medications (such as calcium channel blockers) that can worsen reflux.

▸ Taking antacids or alginic acid.

▸ Not smoking.

▸ Losing weight if obese.

Dr. Harding also suggested that patients try acid blockers (H₂-receptor antagonists and proton pump inhibitors), prokinetic agents (metoclopramide), continuous positive airway pressure in obstructive sleep apnea patients, and surgical fundoplication.

Some sleep patients should be referred to a gastrointestinal specialist for endoscopic screening, she added. These would include patients with dysphagia; older patients with blood loss, anemia, or weight loss; men over 40 who have frequent reflux episodes; and patients not being treated with a proton pump inhibitor.

“There are a lot of esophageal diseases,” she said. “If your patients are not getting better, refer them.”

Dr. Harding disclosed that she receives grant support from and is a contributor to AstraZeneca LLP, maker of a proton pump inhibitor.

SCOTTSDALE, ARIZ. — Patients with sleep disorders should be screened for gastrointestinal reflux, Dr. Susan M. Harding advised at a meeting on sleep medicine sponsored by the American College of Chest Physicians.

Heartburn is common in patients with sleep complaints and can make their sleep problems worse, according to Dr. Harding, a professor of medicine and medical director of the Sleep/Wake Disorders Center at the University of Alabama, Birmingham.

It has not been shown to cause sleep disorders, or vice versa, she said. Nonetheless, researchers have demonstrated that treating gastrointestinal reflux can improve sleep—and that treating sleep disorders can improve reflux.

In one study cited by Dr. Harding, 62% of obstructive sleep apnea patients had symptoms of nighttime reflux. The patients who were compliant with continuous positive airway pressure therapy reduced their symptoms by 48%. Noncompliant patients had no improvement (Arch. Intern. Med. 2003;163:41–5).

Conversely, Dr. Harding cited a trial that enrolled 650 reflux patients with sleep complaints. Four weeks of treatment with a proton pump inhibitor significantly reduced sleep disturbances and improved sleep quality (Am. J. Gastroenterol. 2005;100:1914–22).

“Nighttime reflux is common in heartburn patients,” she said. “It causes sleep difficulties, and it is inadequately treated.”

Stable sleep protects against reflux, according to Dr. Harding. Esophageal acid take much longer to clear during sleep, and people swallow less often. Acid clearance mostly occurs during arousals.

“Is there an association between sleep-related reflux and obstructive sleep apnea?” she asked rhetorically. “Maybe. Maybe not.”

Despite identifying reflux in many obstructive sleep apnea patients, Dr. Harding noted that studies have failed to find a causal relationship or correlations among reflux scores, apnea severity, and other variables by which the two conditions are measured.

The conditions coexist in many patients, she said, which suggests that the relationship may be complex. “Reflux is not caused by obstructive sleep apnea, but reflux may be facilitated by obstructive sleep apnea,” she said, and called for more studies examining transient lower esophageal sphincter relaxations in obstructive sleep apnea patients.

Reflux should be considered whenever a patient presents with insomnia or excessive daytime sleepiness, according to Dr. Harding. Patients with erosive esophagitis are prone to sleep disturbances, she said, and nocturnal reflux has been shown to trigger respiratory symptoms in asthma patients. Sleep-related laryngospasm also can be triggered by reflux.

Consider doing esophageal pH monitoring along with polysomnography, Dr. Harding advised. If sleep-related reflux is diagnosed, urge patients to make the following lifestyle modifications (Arch. Intern. Med. 2006;166:965–71):

▸ Not eating for 2 hours before bedtime.

▸ Raising the head of the bed by about 6 inches using stacked bricks or a wedge.

▸ Avoiding certain foods (fats, caffeine, tomato products, sodas, and so forth).

▸ Avoiding medications (such as calcium channel blockers) that can worsen reflux.

▸ Taking antacids or alginic acid.

▸ Not smoking.

▸ Losing weight if obese.

Dr. Harding also suggested that patients try acid blockers (H₂-receptor antagonists and proton pump inhibitors), prokinetic agents (metoclopramide), continuous positive airway pressure in obstructive sleep apnea patients, and surgical fundoplication.

Some sleep patients should be referred to a gastrointestinal specialist for endoscopic screening, she added. These would include patients with dysphagia; older patients with blood loss, anemia, or weight loss; men over 40 who have frequent reflux episodes; and patients not being treated with a proton pump inhibitor.

“There are a lot of esophageal diseases,” she said. “If your patients are not getting better, refer them.”

Dr. Harding disclosed that she receives grant support from and is a contributor to AstraZeneca LLP, maker of a proton pump inhibitor.

SCOTTSDALE, ARIZ. — Patients with sleep disorders should be screened for gastrointestinal reflux, Dr. Susan M. Harding advised at a meeting on sleep medicine sponsored by the American College of Chest Physicians.

Heartburn is common in patients with sleep complaints and can make their sleep problems worse, according to Dr. Harding, a professor of medicine and medical director of the Sleep/Wake Disorders Center at the University of Alabama, Birmingham.

It has not been shown to cause sleep disorders, or vice versa, she said. Nonetheless, researchers have demonstrated that treating gastrointestinal reflux can improve sleep—and that treating sleep disorders can improve reflux.

In one study cited by Dr. Harding, 62% of obstructive sleep apnea patients had symptoms of nighttime reflux. The patients who were compliant with continuous positive airway pressure therapy reduced their symptoms by 48%. Noncompliant patients had no improvement (Arch. Intern. Med. 2003;163:41–5).

Conversely, Dr. Harding cited a trial that enrolled 650 reflux patients with sleep complaints. Four weeks of treatment with a proton pump inhibitor significantly reduced sleep disturbances and improved sleep quality (Am. J. Gastroenterol. 2005;100:1914–22).

“Nighttime reflux is common in heartburn patients,” she said. “It causes sleep difficulties, and it is inadequately treated.”

Stable sleep protects against reflux, according to Dr. Harding. Esophageal acid take much longer to clear during sleep, and people swallow less often. Acid clearance mostly occurs during arousals.

“Is there an association between sleep-related reflux and obstructive sleep apnea?” she asked rhetorically. “Maybe. Maybe not.”

Despite identifying reflux in many obstructive sleep apnea patients, Dr. Harding noted that studies have failed to find a causal relationship or correlations among reflux scores, apnea severity, and other variables by which the two conditions are measured.

The conditions coexist in many patients, she said, which suggests that the relationship may be complex. “Reflux is not caused by obstructive sleep apnea, but reflux may be facilitated by obstructive sleep apnea,” she said, and called for more studies examining transient lower esophageal sphincter relaxations in obstructive sleep apnea patients.

Reflux should be considered whenever a patient presents with insomnia or excessive daytime sleepiness, according to Dr. Harding. Patients with erosive esophagitis are prone to sleep disturbances, she said, and nocturnal reflux has been shown to trigger respiratory symptoms in asthma patients. Sleep-related laryngospasm also can be triggered by reflux.

Consider doing esophageal pH monitoring along with polysomnography, Dr. Harding advised. If sleep-related reflux is diagnosed, urge patients to make the following lifestyle modifications (Arch. Intern. Med. 2006;166:965–71):

▸ Not eating for 2 hours before bedtime.

▸ Raising the head of the bed by about 6 inches using stacked bricks or a wedge.

▸ Avoiding certain foods (fats, caffeine, tomato products, sodas, and so forth).

▸ Avoiding medications (such as calcium channel blockers) that can worsen reflux.

▸ Taking antacids or alginic acid.

▸ Not smoking.

▸ Losing weight if obese.

Dr. Harding also suggested that patients try acid blockers (H₂-receptor antagonists and proton pump inhibitors), prokinetic agents (metoclopramide), continuous positive airway pressure in obstructive sleep apnea patients, and surgical fundoplication.

Some sleep patients should be referred to a gastrointestinal specialist for endoscopic screening, she added. These would include patients with dysphagia; older patients with blood loss, anemia, or weight loss; men over 40 who have frequent reflux episodes; and patients not being treated with a proton pump inhibitor.

“There are a lot of esophageal diseases,” she said. “If your patients are not getting better, refer them.”

Dr. Harding disclosed that she receives grant support from and is a contributor to AstraZeneca LLP, maker of a proton pump inhibitor.