From the Guidelines
For patients with GERD and a 10-year smoking history, I strongly recommend a comprehensive approach that prioritizes smoking cessation and addresses both conditions to minimize morbidity, mortality, and improve quality of life. This approach is crucial as smoking worsens GERD by reducing lower esophageal sphincter pressure, decreasing salivary bicarbonate production, and impairing esophageal clearance of acid 1. First-line treatment includes proton pump inhibitors (PPIs) such as omeprazole 20-40mg daily, esomeprazole 20-40mg daily, or pantoprazole 40mg daily, taken 30 minutes before breakfast for 8-12 weeks initially, as suggested by the 2016 Chest guideline for chronic cough due to gastroesophageal reflux in adults 1. Lifestyle modifications are also crucial and include:
- Elevating the head of the bed 6-8 inches
- Avoiding meals within 3 hours of bedtime
- Eliminating trigger foods (caffeine, chocolate, alcohol, fatty/spicy foods)
- Smoking cessation, which can be facilitated by nicotine replacement therapy, varenicline (Chantix), or bupropion SR, as these methods have been shown to be effective in aiding smoking cessation 1. If symptoms persist despite 8 weeks of PPI therapy, consider doubling the dose, adding an H2 blocker at bedtime (ranitidine 150mg or famotidine 20mg), or referral for endoscopy to evaluate for complications like Barrett's esophagus, which occurs at higher rates in smokers with GERD, as noted in the 2002 JAMA study on gastroesophageal reflux, Barrett esophagus, and esophageal cancer 1. It is essential to prioritize the patient's overall health and take a multifaceted approach to manage both GERD and smoking cessation to achieve the best possible outcomes in terms of morbidity, mortality, and quality of life.
From the Research
GERD in Patients with 10-Year Smoking History
- GERD is a common gastrointestinal diagnosis, and its prevalence appears to be on the rise, with approximately one quarter of people living in western countries having experienced GERD 2.
- Risk factors for GERD include hiatus hernia, obesity, high-fat diet, tobacco smoking, alcohol consumption, pregnancy, genetics, and some medications 2.
- Tobacco smoking is a significant risk factor for GERD, and patients with a 10-year smoking history are likely to be at increased risk of developing GERD symptoms 2, 3.
- The cardinal symptoms of GERD are troublesome heartburn and regurgitation, and diagnosis can be confirmed by taking a patient-centered history and, if necessary, classified by endoscopic investigation 2.
- Effective pharmacological treatments for GERD include antacids, alginate, histamine H2 receptor antagonists, and proton pump inhibitors, which can help control symptoms and prevent complications 2, 4.
Management of GERD in Smokers
- Lifestyle modification, including dietary recommendations and weight loss, can help manage GERD symptoms in smokers 3.
- Breathing exercises, such as those that induce a change from thoracic to abdominal breathing, may also be beneficial in improving gastroesophageal reflux symptoms in some patients 3.
- Smoking cessation is crucial in managing GERD in smokers, and pharmacological treatments such as nicotine replacement therapy, bupropion, and varenicline can be effective in helping patients quit smoking 5, 6.
- Varenicline, a partial agonist at nicotinic alpha4beta2 receptors, has been shown to be at least as effective as bupropion for smoking cessation, and may be a useful option for patients with GERD who are trying to quit smoking 6.