Sarah Murphy, MD, and Hana Grobel, MD
Mary (not her real name) is a 45-year-old woman who originally
presented with mild gastroesophageal reflux disease (GERD) and was started on a
proton pump inhibitor. When we first saw her three years later, she was still on
As family physicians, we see many patients like Mary who are initially prescribed
PPIs for mild GERD, continue their medication for a long time, and subsequently
suffer various side effects associated with PPIs. The question that arises is how
to safely wean these patients off PPIs. One possible answer is to use an integrative
But first, let’s back up and consider the function of the entire gastrointestinal
tract and the processes that are involved in maintaining the health of our guts.
Taken as a whole, the GI tract is one of the largest organs in our body, and its
surface area can expand to the size of a tennis court. In our lifetime, we take
in 30-40 tons of food that we break down, process, sort, and then use or eliminate.
In addition to the cells of the GI tract, the gut contains 100 trillion bacteria
(400 different species), which is 10 times more than the amount of cells we have
in our entire body. These bacteria break down food to make nutrients more available,
inhibit pathogenic bacteria, and form a layer on the gut mucosa, which protects
the intestinal lining and communicates with the enteric immune system.[1,2]
From the perspective of integrative medicine, when we ingest substances that
harm this delicate ecosystem, the gut barrier can break down (known as increased
intestinal permeability), the microbial ecology can become imbalanced (called dysbiosis),
and we can ultimately get sick. Disease not only shows up in the form of GI disorders
(e.g., GERD, IBD, IBS, gastroenteritis), but can also present as systemic problems.
When the gut mucosa is disrupted, it can become inflamed. Through the more permeable
intestinal walls, improperly digested food substances can cross the GI mucosa and
trigger further inflammation.
How do we keep our guts healthy and our immune systems intact?
One integrative approach is to use the 5Rs of Functional Medicine, where the goal
is to support optimal GI health and address the underlying mechanism of disease.
The 5Rs stand for remove, replace, repopulate, repair and rebalance. These methods
can be applied to many GI conditions, including GERD.
The problem with GERD is not that there is too much acid, but that the acid is
in the esophagus rather than the stomach. PPIs block the secretion of acid, thus
eliminating symptoms, but they do not address the underlying problem of regurgitation
of the gastric lumen contents into the esophagus. In other words, PPIs don’t cure
GERD; they only treat the symptoms.
Over time, the body upregulates acid production to compensate for the lack of
acid secretion, so stopping PPIs becomes difficult because of rebound symptoms.
Some studies have found that long-term PPI use is associated with hyperplasia from
increasing gastrin production, as well as increased gastric atrophy.[5,6] Although
long-term PPI use has been associated with an increased incidence of gastric cancer,
no direct link has been established.
PPIs are valuable in the short-term treatment of GERD, but long-term use may
lead to serious complications, including increased risk for pneumonia and Clostridium
difficile, and decreased absorption of vitamin B12, calcium, magnesium and iron.[7-12]
In fact, our patient Mary was found to be Vitamin B12 deficient.
Despite these potential complications, PPIs are recommended in many circumstances,
such as preventing gastrointestinal bleeding in elderly patients on NSAIDs. As with
other medications, physicians need to balance the risks and benefits of PPIs, depending
on the condition. They should also bear in mind that many patients are on PPIs with
no good indication.
The long-term side effects of PPIs make sense based on the multiple
roles of acid in the stomach. Acid functions to kill bacteria in the stomach, and
it helps break down food to make nutrients more available. In the duodenum, acid
helps stimulate release of pancreatic enzymes, which further aid digestion. Higher
acidity in the stomach also increases the tone of the lower esophageal sphincter.
Thus, acid production plays an important role in tightening LES tone, getting rid
of unwanted bacteria, and providing us with properly digested nutrients.
Our goal with Mary was to wean her off PPIs and help her regain the normal function
of her GI system. We used an integrative approach based on the 5Rs, as outlined
below. Such an approach should begin at least one week before starting to wean patients
Remove. To stop symptoms and prevent their return, it is important
to remove the triggers. Certain foods can be aggravating, including caffeine, spicy
foods, alcohol, chocolate, fatty foods, dairy, and acidic foods, such as orange
juice and tomatoes.[13,14] To identify triggers, patients can use a food diary to
document food intake and symptoms. Alternatively, patients can try an elimination
diet where specific foods are eliminated from the diet for 2-4 weeks, and re-introduced
one at a time to see if symptoms return. Other triggers may include tobacco
use, increased weight, prone position, stomach distention and stress. For some
patients, addressing lifestyle factors may be enough to stop their GERD symptoms.
Don’t underestimate the power of tobacco cessation, weight loss, propping the head
of the bed 4-6 inches, eating meals several hours before lying down, eating smaller
meals and stress management.
Replace. Once the main triggers are removed, non-aggravating
nutritious foods can take their place. Patients may also benefit from replacing
vitamin B12, calcium, magnesium or iron, if low. In addition, one small study
found that, instead of suppressing acid, some patients may benefit from supplementing
with acid to increase LES tone, break down food and stimulate digestion.
Repopulate. Patients who suffer from small bowel bacterial overgrowth
after long-term suppression of stomach acid may benefit from probiotics. We recommend
at least 10-14 billion units daily, preferably with several different species present.
Some symptoms of bacterial overgrowth include bloating, gas, diarrhea and abdominal
Repair. Various herbs and supplements may help protect and repair
the lining of the gut. Many of them act as demulcents and create mucoprotection
of the esophageal mucosa, but they can also decrease absorption of other medications,
so medication doses must be monitored. One week prior to weaning off PPIs, patients
can start taking one or more of the following herbs:
- Marshmallow (althea officinalis): can be ingested as tea,
up to 5-6 grams daily, or as a tincture, 5 mL after meals.
- Licorice (glycyrrhiza glabra): best taken as deglycyrrhizinated
licorice (DGL) 380 mg tablets, 2-4 tablets taken before meals. Glycyrrhizin
acts as a mineralocorticoid and can cause hypertension, hypokalemia and edema
with prolonged use, so deglycyrrhizinated licorice is recommended.
- Slippery elm (ulmus fulva) root bark powder: one to two
tablespoons of the powder mixed with water and taken after meals and before
bed. To increase palatability, mixture can be sweetened with honey.
- Chamomile (matricaria recutita): used for inflammation
and spasmodic effects. 1-3 grams steeped as tea, 3-4 times a day.
- Throat Coat tea (Traditional Medicinals): contains all
the above herbs (licorice root, slippery elm, marshmallow root), but in smaller
amounts. Can be taken with meals.
Rebalance. The enteric nervous system houses more neurotransmitters
than the brain and makes up 70% of the entire immune system, so stress can affect
gut symptoms.[1,18] Many modalities can be used to help decrease stress and prevent
the return of symptoms. Stress-reduction modalities include biofeedback, relaxation
techniques, meditation, self-hypnosis and journaling. Some studies have found that
acupuncture may be helpful for treating GERD symptoms.[19,20] Regular aerobic exercise
is also recommended when tapering off PPIs, but symptoms can be exacerbated if exercise
occurs right after meals. High-intensity activities like running or cycling
may aggravate symptoms.
When using the 5R approach above, it’s important to taper off
the PPI slowly. The higher the dose, the longer the taper; counsel your patient
to expect rebound symptoms. Begin by decreasing the current PPI dose by 50% each
week until the patient is on the lowest dose once daily. After two weeks on this
dosage, change to an H2 blocker. If the patient cannot tolerate going straight to
an H2 blocker, you can alternate an H2 blocker every other day with omeprazole.
After 2-4 weeks on the H2 blocker, taper or stop altogether. After 2 weeks off the
H2 blocker, try tapering off supplements. Your patient will benefit from continued
As mentioned above, the 5Rs can be used not only for GERD, but also for many
other problems with the GI tract. We encourage our patients to see their symptoms
as a message from their body that something is out of balance. Often patients themselves
identify what is out of balance or come to realize that triggers such as stress
can make their symptoms worse.
For Mary, her food triggers included soda (high in caffeine and acid) and fatty
foods. She cut back on her intake of soda, replacing it with citrus-flavored water
and herbal tea. She incorporated more whole foods into her diet and cut back on
the processed foods. She worked on getting more exercise, starting with walking.
She noted her symptoms were the worst at night, so she tried to eat earlier and
not snack before bed.
We advised Mary to prop the head of her bed upright and described a body scan
meditation that she could do before bed. We also recommended Community Acupuncture,
where she could get treated on a sliding scale. She started chamomile and Throat
Coat tea, several times daily.
Mary incorporated all these changes into her lifestyle prior to attempting the
medication wean. Altogether, her taper from PPIs took 3 months, but now she is free
of GERD symptoms.
- Foods, especially acidic, spicy, fatty foods, alcohol, caffeine and dairy:
Consider elimination diet.
- Increased intra-abdominal pressure: Encourage weight loss, avoid tight-fitting
- Stomach over-distension: Encourage smaller meals and less fluid intake with
meals. Slow down, chew food well and relax while eating.
- Prone position: Eat last meal 4-5 hours before bed, place 4-6” blocks under
head of bed (don’t prop on pillows as this can increase intra-abdominal pressure).
- Smoking: Stop.
- Stress: See “Rebalance,” below.
- Vitamin/mineral deficiencies: Consider B12, magnesium, calcium and iron.
(Goal for B12 > 400 pg/mL. Measure RBC Mg, not serum Mg).
- Consider betaine hydrochloride 650 mg tabs 30 minutes before meals. Start
with lower doses, increase until symptoms return, then back down to previous
dose. Avoid with NSAIDs or steroids.
- If signs/symptoms of small bowel bacterial overgrowth (bloating, gas, diarrhea,
abdominal cramps) from poor digestion, consider probiotics (10-14 billion units
daily, multiple species present).
Add one or more of the following:
- Marshmallow: Tea up to 5-6 g daily or 5 mL tincture prior to meals.
- DGL 3x380 mg tablets OR Sucralfate 1 g after meals.
- Slippery elm: 1-2 tbs powdered root in water OR 500 mg caps OR 5 mL tincture
- Chamomile: 1-3 g in tea, TID to QID.
- Throat Coat tea: Can be taken with meals.
- Decrease stress: Lifestyle changes, mind-body techniques
- Regular aerobic activity: Not right after meals.
- Consider other modalities, such as acupuncture.
Taper off the PPI slowly.
- The higher the dose, the longer the taper. Expect rebound symptoms.
- Decrease the current PPI dose by 50% each week until patient is on the lowest
dose once daily.
- In 2 weeks, change to H2 blocker. If symptoms flare, can alternate H2B every
other day with omeprazole.
- After 2-4 weeks on H2 blocker, try stopping or weaning.
- After 2 weeks off H2 blocker, try tapering off supplements.
- Continue lifestyle modifications.
“GERD patient handouts,” Integrative Medicine for the Underserved
“Integrative approach to GERD,” UW Integrative Medicine
“Rx for your gut,” Santa Rosa Family Medicine Residency handout
Drs. Murphy and Grobel are both Integrative Medicine Fellows at the Santa Rosa
Family Medicine Residency.
The authors do not have any conflict of interest or any financial ties to the
products recommended in this article.
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