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Nighttime Acid Reflux: Is Heartburn Keeping You Up?

Heartburn can create tremendous discomfort during daytime hours, but nighttime acid reflux can positively torment. Freed from the burdens of gravity and regular daytime swallowing, acids creep up into the esophagus and do their terrible work.

Below, two gastroenterologists discuss nighttime heartburn, and how to stop those sleepless nights.

How prevalent is nighttime acid reflux?
MICHAEL WOLFE, MD: It's actually a more significant problem than previously thought. We used to think of heartburn as occurring only after meals. But a recent Gallup poll concluded that nighttime acid refluxis quite common. And, actually, in many situations, it is more bothersome at night than during the daytime.

What happens in the body that creates heartburn pain?
JAMES FRESTON, MD, PhD: Well, acid comes up into the esophagus, where it doesn't belong, and causes the pain. When a person is lying down at night, he doesn't have gravity to pull the acid back down into the stomach, like if he were upright. Also, when a person is asleep, there is less swallowing. Swallowing clears the esophagus of acid, and saliva helps neutralize the acid.

MICHAEL WOLFE, MD: Saliva is a natural antacid. It has bicarbonate inside it. And, of course, saliva is free.

For some people who are medicated for heartburn, there is a breakthrough at night. How often does this happen?
MICHAEL WOLFE, MD: The classic example are the proton pump inhibitors which block the final step of acid production in the stomach. They're a wonderful medication. And most people actually successfully relieve their heartburn by taking one pill a day in the morning. But there are a significant number of people who actually will breakthrough at night. It's called "nocturnal acid breakthrough." And it will occur right in the middle of the night, when someone is sound asleep. Not a good way to start the next day.

But if these medications are turning off acid production, why is there acid there to get through?
JAMES FRESTON, MD, PhD: Well, proton pump inhibitors are used in the morning. And their effect gradually wears off. As their effect is wearing off, the person is lying down. The wearing off of the medication, the loss of gravity, and reduction of saliva and swallowing combine to drive the heartburn in.

What can people do?
MICHAEL WOLFE, MD: Well, staying up all night is one method. Another is to elevate the entire head of the bed. That's great for the patient, but for the person sleeping with the patient, it's not too cool sometimes.

There are certain wedges one can use to raise the entire thorax -- not just the head of the bed with pillows, but rather from the waist up.

But the best thing to do is take a medication if you wake up in the middle of the night. The options include taking an antacid. Antacids will work very quickly, but it's very possible the person will wake up again because the heartburn recurs.

An H2 blocker can be taken, and they will work eventually, but an hour will pass before the person actually is able to fall back asleep.

The third option is to take a combination of the two. The antacid provides quick relief, and the H2 blocker provides sustained relief. This combination is an ideal medication protocol for breakthrough heartburn in the middle of the night.

If a person has frequent symptoms, would you suggest that they take that preventively every night, before going to bed?
MICHAEL WOLFE, MD: The problem with taking this medication preventively is that the H2 blocker, if taken at high doses often enough, will actually lose its effect. We develop a tolerance to the medication. They're best suited for taking on an intermittent basis.

Should people try to set a certain period of time between their dinner and their bedtime?
Yes, that helps. Give yourself two hours after eating, before bedtime. At least. If you've taken a very heavy or large meal, allow for even more time.

How does nighttime alcohol affect heartburn?
It makes it worse. Those people who have a drink at night should take the antacid before the fire starts.

Are there certain foods that people should avoid?
It's largely a myth that spicy foods and hot foods cause heartburn. They may cause discomfort down in the abdomen, but that is dyspepsia, a different condition altogether.

Nighttime acid reflux itself is commonly provoked by fatty foods, citrus, chocolate and lots of coffee. These are the major offenders.


By Mortin - Copyright 2010
Last modification 23/04/210


James Freston, MD, PhD
University of Connecticut Health Center, Farmington, Connecticut

M. Wolfe, MD
Boston Medical Center and Boston University School of Medicine