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There is no free meal when it comes to reflux management

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The recent Federal Drug Administration announcement that generic forms of the popular antacid Zantac, also know as ranitidine, may contain small levels of nitrosodimethylamine, a possible cancer-causing chemical, has led to worldwide concern. 

Some major manufacturers of the drug, including Sandoz and Apotex, have recalled ranitidine tablets on a “precautionary basis.” 

Other manufacturers such as Sanofi, however, have not recalled the drug. A spokesperson for Sanofi, recently responded to the press via email: “The FDA reported that the levels of N-nitrosodimethylamine in raniditine in preliminary tests barely exceed amounts found in common foods.” 

Pharmacy chains such as Walgreens, Rite-Aid, and CVS, as well as distributors such as Walmart, have already suspended Zantac sales. 

The FDA, however, has not issued a formal recall but has instead advised patients to discuss alternative medication options with their physicians. This has led to panicked and confused patient phone calls at physician offices across the country, including at my own. 

Although patient/physician discussions regarding these new findings are important, a more important discussion is the one regarding the anti-reflux diet and behavioral modifications that may decrease the symptoms of reflux in a more natural way. 

Gastroesophageal reflux disease (GERD) is the abnormal movement of acidic and non-acidic gastric enzymes into the esophagus or lower throat. The two most frequent symptoms include heartburn, a burning sensation behind the breastbone, and acid regurgitation, a bitter or sour tasting fluid. Symptoms can also include chronic cough, difficulty swallowing, and voice changes. 

According to a 2014 literature review from the National Institutes of Health, up to 30 percent of the population in North America suffers from GERD. This likely underestimates the true prevalence since many Americans may not seek out a physician for evaluation. A 2014 systematic review placed direct and indirect costs of GERD to be $15-20 billion per year. 

Reflux disease is commonly treated with antacids such as ranitidine, an H2 blocker, and proton pump inhibitors such as Nexium and Prilosec. In recent years, the use of the inhibitors  has grown out of favor due to concerns about malabsorption of calcium, magnesium, and B12 as well as concerns over effects on cardiac and renal function. 

Many considered these H2 blockers the cheaper and safer alternative. With the new concern over ranitidine, one type of H2 blocker, it is now more important than ever for health care providers to discuss natural diet and behavioral changes with patients who suffer from mild, intermittent symptoms of acid reflux. 

Some of these modifications include avoidance of caffeine, alcohol, citrus, carbonation, peppermint, spicy, fried, or high fatty foods. Additionally, eating smaller meals throughout the day, not eating within four hours of bedtime, weight loss, avoiding tight fitting abdominal clothing and sleeping on an incline or wedge may help. 

Physicians need to have frank decisions with their patients regarding lifestyle choices and GERD symptoms. Even if antacids are recommended due to severity of disease, doctors can encourage anti-reflux modifications  

There is no free meal when it comes to reflux management. 

Certainly, antacid medication use is warranted in certain severe cases of acid reflux such as peptic ulcer disease or Barrett’s metaplasia. However, physicians have a responsibility to discuss anti-reflux precautions as a viable alternative to prescribing antacids for uncomplicated GERD. 

The heightened recent concern over the possibly harmful ingredients in Zantac, has forcibly pushed conversations into clinics. This is an opportunity to guide patients to a more natural management of gastro-esophageal reflux disease and less dependence on antacids. 

Inna Husain, MD is an assistant professor, director of the Rush Voice, Airway, and Swallowing Disorders Program, and a Rush Public Voices fellow through The OpEd Project.


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