Transcript. September 17, 2006 The latest treatment and research for acid reflux disease Guest: Hashem El-Serag, M.D., M.P.H. Hosted by Andrew Schorr

Transcription

1 Transcript September 17, 2006 The latest treatment and research for acid reflux disease Guest: Hashem El-Serag, M.D., M.P.H. Hosted by Andrew Schorr Please remember the opinions expressed on Patient Power are not necessarily the views Health Radio, our sponsors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. Please have this discussion you re your own doctor, that s how you ll get care that s most appropriate for you. Introduction Good morning, wherever you may be around the country listening to us on the internet or on Health Radio Network. I'm Andrew Schorr. This is Patient Power, the only show on radio anywhere where week after week we talk about a new medical topic, an important one, serious illnesses, chronic conditions, cancers. I'm a ten-year leukemia survivor now and doing well. So today we're going to be talking about things related to digestion, and I have a mystery guest. Okay. So this man, something very significant happened to him. He is probably the most famous American who has lost a lot of weight. Sir, mystery guest, behind curtain number one, how much weight did you lose? 245 pounds. Okay. You have seen him on television. Yes, it is Jared Fogle, Jared the Subway guy. Jared, do you really have a pair of pants that has like a 60-inch waist? I do. Sadly enough, when I was 20 years old I wore that 60-inch pair of pants and at the point weighed 425 pounds to go along with it. So I was a big boy and obviously needed to make a major, major change in my life. Jared has been on Patient Power a couple of times. You can see it all if you go to patientpower.info on the web. That's our website and just search for Jared Fogle, and we did an hour earlier here in Seattle. Jared is going to be at the Seattle - 1 -

2 Seahawks game. But you may know his story where as a kid he just played more video games than exercised and didn't really pay attention to what he was eating. Even though his father is a physician, lots of medical people in his family, Jared just didn't exercise and didn't eat right. When he got to college then you were up to 400 and? 425 is what I maxed out at before I finally said, you know, well, enough is enough. Okay. And there was a Subway sandwich store downstairs. I lived next door to a Subway restaurant actually. So... Okay. So he set himself up on a low fat diet as much as he could, a nonfat diet there. And over the course of how many months you lost your 245 pounds? Well, the total came off in just under a year. So in about 11 and a half months I was able to lose the entire 245 pounds and luckily have been able to keep it off now for about eight years. Okay. And you're how tall? About 6 2. And you weigh? About 195. The Obesity Connection Okay. Now we're going to broaden this discussion. So with us also is Dr. Hashem El-Serag. Dr. El-Serag is an associate professor and a gastroenterologist at one of the top medical schools in the country down in Houston, Baylor College of Medicine. And so, Dr. El-Serag, people put on weight like Jared did and then there are all sorts of complications, certainly, heart problems and diabetes, but also as they get obese they also wind up with a common condition of acid reflux disease and - 2 -

3 heartburn, right? Yes. Good morning, Andrew. Good morning Jared. Indeed, obesity is thought to be a major risk factor for the condition gastroesophageal reflux disease as well as many other digestive conditions. And Americans are overweight, aren't they? There is an epidemic of obesity in this country. It's thought to be that two-thirds of all Americans are overweight, and we may get to the definition of what means. And obesity is affecting probably 20 percent or so. And there is a major epidemic of obesity in children and adolescents, which really doesn't bode well for the future too. Well, I just mentioned Jared spends his life now going around to schools, and that's why he's here. Jared, I know you've spoken to more than a hundred thousand school-age kids, right? I have, coast to coast, and it's one of the things that I love to do, obviously to see the reactions but I think also to have a positive message to go with it. And the fact is kids look at me not just as an adult or a teacher or a parent, they look at me as Jared the Subway guy from the TV commercials and because of that, hopefully that message carries a lot more weight. Yeah, if they were watching American Idol they saw you a lot. Exactly. What is Acid Reflux Disease I saw you a lot in my house during American Idol

4 Okay. So, Dr. El-Serag, so these kids grow up and they eat certain foods. Now acid reflux disease, we have acid in our stomachs but it's not supposed to be in our esophagus, and that's where it hurts and causes damage, right? Correct. Correct. Acid is normally secreted in the stomach. It's very essential for digestion and protection against bugs, and it's supposed to remain in the stomach where the lining of the stomach is equipped to protect itself from acid. Now, normally some acid sort of trickles from the stomach to the esophagus or the feeding tube, and most normal people are equipped with different mechanisms to clear that acid and protect the esophagus. If those defense mechanisms break down to due to a variety of reasons then you have a lot or excess amounts of acid in contact with the esophagus. The esophagus is not equipped to deal with acid, and it reacts to it in a variety of ways by sloughing off, causing something called erosions, ulcerations, narrowing. But most commonly it presents with the symptom of the so-called heartburn or acid sensation. Okay. So anybody who has watched any television since TV started has seen commercials for Tums, Mylanta and all sorts of antacids. Things that used to be prescription medicines are now over the counter, and then there are new types of prescription medicine. It seems like millions of people are taking these products and this is probably one of the most widespread digestive problems. It is indeed the most common digestive problem. It is estimated that anywhere from 30 to 50 million Americans have the condition. And when I say "the condition," means that people have those symptoms of heartburn and acid regurgitation at least once a week or more. The medications that are used to treat the variety of symptoms of heartburn and regurgitation and gastroesophageal reflux disease are among the top selling medications of any kind of other diseases. So indeed this is a problem and the economic impact of which is great and growing. Okay. I didn't sleep well last night. We did a Leukemia Society Light the Night walk around a lake in Seattle, and with the kids we ended up eating pizza about 10:00 or 10:30, of course, a lot of tomato sauce on the pizza. So maybe not surprisingly around 3 a.m. I woke up with heartburn. And I did take one of those over-the-counter, formerly prescription things I got from the drugstore, sort of the generic kind, and then propped myself on pillows. It seemed to help. Now, that happened to me one time, infrequently. That wouldn't actually be acid reflux disease. That would be just maybe I ate tomatoes too late, or how would you describe that? - 4 -

5 You had as you described, symptoms of heartburn and regurgitation and it is sort of an isolated episode of this gastroesophageal reflux, but you don't have the disease. So what makes people to be defined as having disease? When they have those symptoms frequent enough to affect their quality of life. And a variety of studies have shown that when that frequency exceeds a couple of times a week most people get bothered with this frequently enough that they have to carry medications with them regularly, that it affects their social activities, it affects that they go out and eat exercise, etc. And at that point it is defined customarily as gastroesophageal reflux disease. In a small proportion of patients who have those frequent symptoms serious complications may arise. One is called erosive esophagitis. The lining of the esophagus basically gets ulcerated, and that gives people basically constant symptoms of heartburn and regurgitation. That happens probably in 15 to 20 percent of those who have weekly symptoms. Another manifestation is strictures or narrowing. So repeated erosions or ulcerations that keep healing over time may eventually scar down the esophagus and result in a stricture, and if that happens then people complain of difficulty swallowing or eating. Some manifestation acquiring a lot of press and importance, and for good reasons, is called Barrett's esophagus. That's B-a-r-r-e-t-t. And it is a condition in which the esophagus changes its lining from the normal lining of the esophagus to a lining that resembles the small intestine basically to protect itself from that excessive acid. Doctor, we're going to continue after the break and we'll get more from you on this as we continue with Patient Power. More on acid reflux disease on Patient Power. You're with us live on Health Radio Network. Andrew Schorr here, thank you for being part of our audience on this Sunday. And next to me is Jared Fogle, the Subway guy. Jared lost 245 pounds. You're going to be at the Seahawks game so you don't want it to rain. I was just commenting that I definitely don't want it to be raining because of course we know that the Qwest Field where the Seahawks play is an outdoor stadium. So no rain. Right. Now, Jared, as Dr. El-Serag from Baylor was saying if we can have an impact on obesity we can lower the complications such as acid reflux disease that - 5 -

6 we're just hearing probably by far the most common digestive health condition. So that's what you preach to kids and hopefully they'll talk to their parents about it too. It is. Healthier eating, lower fat food and some exercise. Absolutely. And then you wouldn't have gotten into the shape you were in, 400 and some-odd pounds. Exactly. Yeah, my message when I'm speaking to kids or when I'm speaking to adults is, you know, just try to learn from my mistakes. Try to learn from unfortunately how I let my life become, when I weighed 425 pounds just the things I couldn't do anymore in life, the health conditions that I was already starting to have. And these are the all the things that I really try to talk to kids about and say, You know what, I expect you to make better decisions than I did so that you don't have to go down that road yourself. Okay. Well, we wish you well and applaud the things that you did. Thank you very much. I appreciate it. Complications Associated with Acid Reflux Disease Thanks for being on the show and here in Seattle. Dr. El-Serag, so let's continue now. We talked about the problems of having this acid in a recurring way being in your esophagus. What are the complications that leads to? Well, the most common adverse thing that happens to people with frequent reflux, as I mentioned earlier, impaired quality of life. It seriously impairs the way they go out to eat, the way they exercise, the way they move around because the - 6 -

7 symptoms tend to occur each time they eat or drink, each time they bend over, they exercise, they change position, and it impairs the way they sleep, etc. Those are very important things. In addition there are infrequent but significant complications that may affect the esophagus itself. The most common one of those, which happens probably in 10 to 15 percent of those who have frequent symptoms, is a condition, as I was mentioning, called erosive esophagitis, where the esophagus sort of sloughs its lining and gets eroded and ulcerated. And if that happens it means that their symptoms become much more frequent and much more recurrent and persistent. The other condition that may result from erosive esophagitis is recurrent erosions and scarring that leads to narrowing and stricturing of the esophagus so it narrows down and doesn't allow the passage of food with ease. And those who develop this condition complain of something called dysphasia or difficulty swallowing, where food tends to get stuck and they occasionally have to go in emergently for pieces of food and meat to be dislodged from their esophagus. The other condition which is now we know quite common, may affect anywhere from five to ten percent of those who have frequent symptoms is called Barrett's esophagus. And it is a condition when the esophagus changes its lining from the normal pattern to a pattern that resembles the small intestine. We think it's an adaptive mechanism of the esophagus to deal with acid which it's not used to. But an unintended consequence possibly is that the Barrett's esophagus carry as risk, a small risk, but a definite risk of increased esophageal cancer. That esophageal cancer is called esophageal adenocarcinoma, and it is currently thought to be the fastest rising cancer in Caucasian men in the United States. Still a rare condition. Barrett s Esophagus I just want to mention, I have a neighbor where that's exactly what happened. Exactly. Barrett's esophagus and not a malignant condition but certainly a serious one. But you're right. He did develop exactly that cancer. It's changed his life, and he's a pretty sick guy. Yes. Yes. Unfortunately it could be a potentially serious thing. I think it's important to highlight two points here: That the condition is relatively common, Barrett's esophagus, but the cancer a relatively rare. But once people are diagnosed with this condition they will need to undergo regular surveillance where they undergo this endoscopy with biopsy every two to three years. And this carries potentially a major impact on their quality of life and the way they deal with things - 7 -

8 because to carry this premalignant condition around, it's always on their mind, it may affect the way they deal with things, and it certainly needs close attention. So that's a complication that may happen from reflux disease. And the last one we just alluded to is the actual cancer, esophageal adenocarcinoma. As far as we know, the only premalignant condition to it is Barrett's esophagus, so reflux is we think responsible for most cases of esophageal adenocarcinoma, and it is a very, very bad disease. The survival is quite dismal, and at five years I believe something close to five percent remain alive, so it is something that is unfortunate. A good thing it is rare, but it is potentially a preventable condition. We're visiting with Dr. Hashem El-Serag. Dr. El-Serag is an associate professor and a gastroenterologist at Baylor College of Medicine in Houston, one of the top medical institutions in the country. And then earlier we had on with us a drop in by Jared Fogle who was that fellow who lost all the weight partly by following a healthy diet at Subway, and now he speaks to kids around the country helping them try to avoid obesity, which can be precursor to acid reflux disease that we've been discussing. I want to start talking about treatment, Dr. El-Serag and then we'll continue after the break. So there are all sorts of TV commercials that show these kind of slightly overweight men, typically, who say they get to eat pizza again and meatball sandwiches and all that because they took this medicine over the counter or that. And that sort of begs the question. How do you feel about that? Is that the way to go through live is just sort of eat whatever you want but swallow this pill or take this antacid? Is that the way to go? How do you feel about it? Well, it's slightly philosophical of what people can put up with to do certain things. I think the example you mentioned before the break, you eating that late night dinner very infrequently and having reflux after that, you know that you're going to have some reflux after that and the medications that are available are reasonably effective to relief it. And if it happens infrequently then I think it's a choice that you make. If you want to eat that pizza and get the heartburn, it's your business. But to portray that you can actually do this every meal I think is slightly not correct. If you actually develop those heartburn symptoms every time you eat, then you're not going to have this nonchalant attitude portrayed on TV where you just go about life popping pills every time. I think at that point in time most people are not very happy with this, and they feel quite handicapped by it. Again, the issue of quality of life you could say, well, it's up to you. But there is that certain risk of real serious disease in terms of esophagitis, stricture, Barrett's and esophageal adenocarcinoma that may result from this prolonged chronic reflux - 8 -

9 disease, and therefore the idea that you can gain weight and eat and have reflux all the time and pop pills and nothing will happen is probably not correctly true. Okay. Let's take another break, Dr. El-Serag. We're going to continue our discussion with Hashem El-Serag, gastroenterologist from Houston Baylor College of Medicine as we continue on Patient Power right after this. Other Negative Effects of Obesity Welcome back to Patient Power live on Health Radio Network. I'm Andrew Schorr. Today we're visiting with Dr. Hashem El-Serag. Dr. El-Serag is a gastroenterologist and he's an associate professor at the Baylor College of Medicine in Houston. And earlier in the program, Dr. El-Serag, we had on Jared Fogle, who's known on television as the guy who lost all that weight, and now he's a spokesperson for Subway sandwich shops, not just for healthy eating through there but just healthy eating and exercise to limit obesity. So we talked about it being related to acid reflux disease and heartburn, but I guess as a physician you should probably mention all the other bad things that go with obesity too, right. Absolutely. Absolutely. So while reflux is important there are many other important and potentially fatal conditions that are linked to obesity like heart disease, heart attacks, strokes, variety of cancer, joint problems and in general shortened life expectancy and increased hospitalizations and physician visits, etc. There's no question that obesity should be and it's on its way as being classified as a disease itself, and therefore it should be avoided not only for the gastroesophageal disease but a whole variety of reasons. Okay. Well, we'll say that time and again on Patient Power, and I know I'm working hard with my kids to do things together, just active things that help their weight and mine as well. But as far as acid reflux disease goes, let's understand the range of things that are available to control it. One is trying to lose weight so at the very start are there certain foods in adults that tend produce acid that we might want to consider not having be part of our diet and then this might be less of a problem to begin with? - 9 -

10 Diet and Acid Reflux Yes. So it goes back to obesity. The first step is a lifestyle factor, and that should be done whether alone it relieves the symptoms or whether someone is taking medications because it reduces the requirement for medications. And as you said losing weight, avoiding certain types of diet, particularly things such as chocolate, tomato-y juices, acidic contents such as citrus fruits, etc. But reality is that works at an early stage of the disease. Once people have frequent symptoms that recur on daily basis virtually every type of food would precipitate the symptoms. So avoidance is helpful but probably just in an early stage and someone like yourself and you described your last night adventure. A lot of tomato sauce. Some tips that are useful especially when people go to sleep, which is a favorite time for GERD to act up, is to elevate the head end of the bed a little bit. That's not done by just putting a couple of pillows under your head. There's certain ways you can put blocks under the head end of the bed to elevate it by a couple of inches or so, and that helps reduce the symptoms that happen during nighttime. So those lifestyle factors in addition to eating healthy, exercising, etc., will have some impact on the frequency and severity of GERD. Just one thing about the bed, though. Dr. El-Serag, there are also those ads on TV for these expensive beds that can tilt all over the place. You're not saying somebody needs to go out and buy one of those expensive beds. No, I don't. But just sort of elevation. No. In very rare instances people actually regurgitate large volumes of food then they sort of choke on it when they're sleeping, and maybe in those instances those beds would be required. But for the large majority of people this is not what I'm talking about. I'm talking about just simple, cheap measures

11 Treatments Okay. So these are things you can do yourself. What about over-the-counter products. They're basically neutralizing the acid, right? Correct. I mean the first thing I heard, you were saying increase the acid production. It's important to remember that the stomach acid is really normal. It's not increased. It just happens to contact the esophagus in an abnormal amount. So the medications that are over the counter are basically two groups. One of them just neutralizes the acid that is already there, just puts out the fire, if you will. And those are the antacids. And I'm just going to mention a couple of examples, not necessarily endorsing them, things such as Tums, and Mylanta and Gaviscon, things like that. They work instant, almost instantaneously, within a couple of minutes, because what they do is really neutralize the existing acid, and they help to relieve symptoms or prevent them if you know that you're eating your meal like within the next couple of minutes because their half life or the duration of action is very short. It's just in terms of minutes. It doesn't even last for an hour. And they work at that point in time and their effect sort of doesn't last. The other types of classes of medication, they work on inhibiting or reducing or preventing the stomach from producing acid in the first place. And among those medications there are two broad classes. One we call histamine-2 blockers. And the famous examples are the Tagamet, Pepcid, Axid, and those were the first generation of medications. They take 30 minutes to an hour to start working. Their effect lasts from anywhere from four to six hours, and they have to be taken repeatedly for someone who has recurrent symptoms. But for someone who just has infrequent symptoms they usually do the trick by covering a long part of the day. New and More Effective Medication The newer and the most effective and the longest lasting medications are the so-called proton pump inhibitors. Omeprazole, or Prilosec, was the first to come on the market. Since then there have been several others. Rabeprazole, which is Aciphex; esomeprazole, which is Nexium; Protonix, which is pantoprazole; and others; lansoprazole, which is Prevacid. So one of them is available currently over the counter, which is Prilosec. Those medications take some time to work, so they take probably an hour. They need to be taken before food or food has to be taken around the same time, or it will last for anywhere from 12 to 16 hours so theoretically it works the whole day

12 Dr. El-Serag, we're going to take a quick break and continue our discussion about the treatments that are available and when to see the doctor as we continue on Patient Power as we're talking about acid reflux disease. So Dr. El-Serag from Baylor, let's continue. Help us understand then that range of treatments, and then I want to get into how do you know when to go to the doctor. All right. So the treatments are either medical, which is used in the great majority of patients, or surgical, and I'll talk about that in a little bit. Among the medical, there are many over-the-counter preparations. Antacids and Gaviscon are one category. They work quick. Their effect doesn't last for long. They could be used for those with infrequent symptoms or those who are already on stronger medications who have breakthrough symptoms that they need to supplement it with. The other category of medications are histamine-2 blockers, again available over the counter but also available in prescription double the strength of that in overthe-counter. The examples are Tagamet, Axid, Pepcid. And those medications take a little bit longer to work than antacids, but their effect lasts longer. Again, they work or they should be used for those that have symptoms that are not that frequent. When once you get to using it ever day their effect tends to not last as long, and they tend not to be as effective especially on those who have erosive esophagitis, strictures or Barrett's esophagus. The third category is called proton pump inhibitors. Prilosec OTC is the only one available over the counter. The rest, four or five of them, are available by prescription. They are the strongest and the longest lasting effect of all categories, and they're really indicated for those with recurrent frequent symptoms or those with complications such as esophagitis, stricture and Barrett's esophagus. I think for most people who have infrequent symptoms that are precipitated by known foods they probably will do just fine with the over-the-counter preparations. For those who start having more frequent symptoms that happen several times a week or on a daily pattern, then I think this is the time to consult with at least their primary care physician. It helps, depending on the age, the weight, other medical conditions, for their primary care provider to make sure that it's not something else apart from GERD and to administer or to give them prescription strength medications whether histamine-2 blockers or proton pump inhibitors. For those who have difficulty swallowing, for those who have anemia, for those who have blood coming out of their mouth or their rectum, those who have abnormal blood tests by their primary care provider, those who have symptoms for let's say longer than four to five years, I think this is the category the people or the subgroup that should be referred to a specialist, namely a gastroenterologist. And

13 the reason for referral becomes to make sure that complications haven't developed such as narrowing or stricture or Barrett's esophagus or, god forbid, cancer. And for this category of patients most specialists would write the latter category the medications, which is proton pump inhibitors, that may have to be taken for long time period s, years or for life if there is such a thing. It is important while they're doing all of this that the lifestyle factors, such as eating healthy foods, reducing fatty foods, increasing fiber, losing weight, exercising, exercise at the same time as they reduce the requirements for medications. Now, for a very small category of those with severe disease that do not respond to the maximum therapy, medical therapy of proton pump inhibitor, there is a surgery that might be indicated to those patients. So those who are refractory to medical therapy or in unusual circumstances where patients are allergic to all available medications or they really don't want or can't take medications, then surgery is required in that case. And the surgery basically consists of wrapping part of the stomach around the lower end of the esophagus thus preventing the reflux from happening. As other surgeries, it requires general anesthesia. It's an invasive procedure. It has a very low mortality, but still there is a mortality associated with the surgery. And there are a variety of complications. So I don't regard this as a first line of therapy but rather sort of a last resort. Right. I want to make a point there, we always do on Patient Power, and that is don't go into surgery lightly. And this is something definitely where I would urge people to get a second opinion for. So you're going step-wise through a range of treatments and then if surgery is indicated I would check with someone else. Dr. El-Serag, we're going to come back after the break and get some final thoughts from you. We've been discussing acid reflux disease that affects so many people on Patient Power. And the replay will be on our website both healthradionetwork.com and patientpower.info. We'll be back with some final comments on this topic right after this. Stay with us on the health radio network. Recommendations for Treating and Preventing Heartburn Thanks for being with us this Sunday, kind of gloomy in Seattle but no rain as we look forward to a Seattle Seahawks game. Hopefully they'll make it through the Super Bowl this year. If you're from Pittsburgh you'll probably say naah. But anyway that's what I'm thinking about as we go on, but I'm happy that we talked about acid reflux disease that affects so many people. And our guest has been, besides Jared from Subway who was with us earlier and argues for of course us

14 keeping our weight under control for our kids too, which is so important. We've had with us Dr. Hashem El-Serag who's a gastroenterologist at Baylor College of Medicine in Houston. Dr. El-Serag so when you think about this topic what do you want to leave people with so hopefully the millions of people who are affected can live better? Yeah. I would like to say that it is a common condition and increasing, that although for the great majority it's a major convenience of quality of life, in a small minority it can result in serious complications that may end into cancer. It's a small risk, but it's there. That there are many things that people can do conservatively without medication, such as losing weight eating healthy. And that there are many available medications over the counter that help to relieve symptoms in those with infrequent symptoms or those with breakthrough symptoms. That your doctor or provider should know when you start having frequent symptoms or when you start having difficulty swallowing or losing weight or losing blood because there are tests that need to be done to investigate the complications of this disorder. That there are available strong medical therapies for it that are reasonably save. And there is as a last resort a surgical option that could help people cope better with this problem. What a great conclusion. Dr. El-Serag, thank you for being with us, from Baylor in Houston. We wish you well. We'll have you back sometime, okay? Thank you very much. Would love that. And I'm eager to see our Houston Texans win, and good luck to you and to Jared and to your audience. Thanks for having me. Thank you, sir. Now as we look ahead again, next week we're going to have on Dr. Alan Goldsobel who's from another medical specialty, immunology. He's an asthma and allergy specialist, and so many millions of people are affected by allergies and often not just in the spring but in the fall they act up. And also asthma is another condition where unfortunately too few people have it under control. Please remember the opinions expressed on Patient Power are not necessarily the views of Health Radio, our sponsors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. Please have this discussion you re your own doctor, that s how you ll get care that s most appropriate for you