Nocturnal GERD/OSA/CPAP - Wakeup call

[roster]

http://cme-online.med.upenn.edu/index.p ... iid=298124

Looks interesting. Is anyone here a subscriber?

[Loveylouise]

you can register for the class for free and listen to it
Louise

[Guest]

Doctor told me to put a 2 x 4 under the head of the bed for nightime Gerd. However I was sleeping on a waterbed and couldn't do it. He put me on Prilosec and that takes care of the problem.

[roster]

Thanks Louise, the registration is free. I watched three of the presentations so far and found them fascinating. I would love to see a discussion started in this thread among members who actually watch the presentations.

I assume doctors make up the audience during the presentation. The presenter gives "tests" and the audience keys in their answers. Notice that 60% or less of the audience (doctors) can answer any multiple choice question correctly!

I hope to hear opinions on the studies presented from some of you.

[socknitster]

Rooster,

Thanks for posting this. I'll be watching them soon!

jen

[Guest]

well that was a good hour long lecture...seems the GI's want a larger slice of the sleep money pie.

think I fell asleep during the 2nd speakers presentation, had a NERDY GERDY event, had to take a PecidComplete to finish out the rest and the 3rd speaker needs to stop taking audience polls

but I did find it interesting in the 3rd's presentation slide show a strong correlation between the reflux event and "spontaneous" arousals. The 3rd speaker seems to insinuate that those may be more associated. Better answer than I've seen so far.

I also learned that a PPI is supposed to be effective in reducing those NERDY symptoms and the lowering of sleep arousals seen, but when compared to placebo they were no more effective?

...mmm I was on a PPI (prescription Prevacid) during all my PSG's, wonder how that may have impacted the outcome of those?

[roster]

well that was a good hour long lecture...seems the GI's want a larger slice of the sleep money pie.

think I fell asleep during the 2nd speakers presentation, had a NERDY GERDY event, had to take a PecidComplete to finish out the rest and the 3rd speaker needs to stop taking audience polls

but I did find it interesting in the 3rd's presentation slide show a strong correlation between the reflux event and "spontaneous" arousals. The 3rd speaker seems to insinuate that those may be more associated. Better answer than I've seen so far.

I also learned that a PPI is supposed to be effective in reducing those NERDY symptoms and the lowering of sleep arousals seen, but when compared to placebo they were no more effective?

...mmm I was on a PPI (prescription Prevacid) during all my PSG's, wonder how that may have impacted the outcome of those?

Thanks to you, Snoredog, and some others I had an upper endoscopy in June and was diagnosed with silent GERD and they also found ectopic gastric mucosa in my upper esophogeal sphincter (stomach lining cells in the esophagus where esophagus cells should be - a birth defect).

18 months of cpap and the sleep doc tinkering with the pressure and prescribing sleeping pills and sedatives and I still have some anxiety and other symptoms of sleep deprivation. I quit sedatives and sleeping pills six weeks back and I felt less bad since then. I am beginning to think the cpap is ok but the GERD and ectopic gastric mucosa are a problem with arousals.

Question 1: The gastroenterologist prescribed a PPI before dinnner each night (and also head of bed elevation). Based on what I heard in the lecture should I switch the PPI to before breakfast? I am having very little anxiety at night since I started the PPI.

Question 2: In the lecture they talk about silent GERD causing arousals that may not be within the limits of a PSG to detect. Oh heck, I forgot my question - remember I am sleep deprived. But it had something to do with these suspected arousals.

Opinions will be appreciated.

[Snoredog]

Question 1: The gastroenterologist prescribed a PPI before dinnner each night (and also head of bed elevation). Based on what I heard in the lecture should I switch the PPI to before breakfast? I am having very little anxiety at night since I started the PPI.

Well I'm no expert, but:

A Proton Pump Inhibitor would turn OFF nearly all the stomach's acid making ability. Of course not mentioned in this lecture is the down side of "Continuous" use of those PPI's. It is controversial because that stomach acid is also thought to be your body's first line of defense against bacterial infections. In this day and age of our FDA's ability to protect us from E coli outbreaks to tainted dogfood, do you want to be without that protection?

The 2nd Speaker outlined the effectiveness of PPI's, "Continuous" therapy as compared to "Intermittent" as compared to on "Demand". On "demand" didn't make much sense to that speaker due to the time it takes for the drug to turn off your Proton Pumps acid making ability. I disagree with him, I can take a PecidComplete and get relief from reflux within minutes. But his point was that if you are awaken due to an arousal related to GERD, then taking something for it at that time is too late. Intermediate was taking the PPI for several days when you are experiencing flare-ups or symptoms and his preferred method was "continuous" treatment or taking a PPI pill every day concept (this message brought to you by the makers of the purple pill -viagra!).

As for the half-life of the PPI you are using? You would have to read up on the Prescribing information for the drug itself to learn how long it takes for that drug to inter your blood stream and turn off those pumps and becomes effective. If it takes 12-hours for that to happen then maybe you do want to take it before Breakfast. But if it's half life is only 12 hours it may do nothing during the night when it is needed. Food and drink increases your acid production, that I think is why they want you taking it before breakfast. As mentioned in the lecture, most "refluxing" was seen during the first 2 quarters of the night or first half of the night, so you want all acid making ability stopped "before" that period happens.

Question 2: In the lecture they talk about silent GERD causing arousal's that may not be within the limits of a PSG to detect. Oh heck, I forgot my question - remember I am sleep deprived. But it had something to do with these suspected arousal's.

Think one of the presenters (1st or 3rd?) indicated they did a catheter "injection" of a saline solution (1ml?) below the Upper Esophageal Sphincter (UES) and it showed a response to the UES closing, it also showed an awakening arousal on the EEG, some patients went all the way back to "Wake" while others these arousals left them in Stage2 and they were completely unaware of the event waking them even if they went back to the "wake" state for a few seconds. So basically you are not going to remember these, BUT they did say that arousal was thought to be associated with daytime fatigue. The last part of the 3rd lecture was about Silent Gerd.

I agree that if you have GERD symptoms during the day, you are most likely to also have them at night even if no symptoms are present.

With today's recording APAP's, a person should be able to "see" if taking a PPI improves or lessens the frequency of arousals seen, but that would only be in the form of obstructive sleep disordered events as you have no EEG to monitor that activity.

But I've elevated my bed (wacked off 2" of the legs on the bed frame) and take either a PPI or PecidComplete before bed and had zero events seen on my 420's reports.

My GI Specialist is also a Professor at UCSF, where the 2nd speaker taught and practices.

I think the best thing you can do is elevate your bed at the headboard end.

[roster]

The PPI my doc prescribed is Prevacid. As far as determining when to take it, the product literature states, "The plasma elimination half-life of lansoprazole is less than 2 hours while the acid inhibitory effect lasts more than 24 hours. Therefore, the plasma elimination half-life of lansoprazole does not reflect its duration of suppression of gastric acid secretion".

If I compare information in the product literature for Prevacid and Pepcid AC (not Prevacid AC Complete), the Pepcid AC achieves a higher ph for 10 hours. (The way the data are presented is such that an exact comparison is not possible).

For nocturnal GERD, I believe that taking a dose of Pepcid AC two hours before bedtime would be more effective than taking a dose of Prevacid anytime during the day (strictly my estimate/opinion). Again, the tables in the respective product literature do not allow an exact comparison, but the way the data are presented lead me to prefer the Pepcid AC.

But it may be more complicated than this, because I suspect that acid levels during the day can have an effect on nighttime sleep. So in the meantime, I am switching my dose of Prevacid to before breakfast and I will see if I feel better or worse.

As far as Pepcid AC Complete acting quickly, this is probably due to the calcium carbonate neutralizing stomach acid. Pepcid AC Complete sure seems like a good way to go except that the calcium carbonate causes some digestive distress for me.

Snoredog, I also suspect that raising the head of the bed some sufficient amount may be more effective than any pharmacological solution.

[socknitster]

Rooster. have you tried sleeping on a wedge? I have been happy with my MedSlat brand wedge from Amazon. It is long enough to reach the hips rather than just the head and shoulders like most wedges on the market. I believe it is 30+ inches long.

I mention this in case your wife isn't interested in raising the head of the bed. I didn't even ask my husband because I knew the long suffering sigh I would hear!

I am very interested in your discussion with Snoredog. Being a sufferer of silent gerd myself, I have been taking prilosec otc for the last month. I am reluctant to continue it long term, knowing the side effects snoredog mentioned. The other brands you mentioned, taken with the evening meal might be a good compromise for me. I never suffer from reflux during the day and I was hoping to switch to a less strong brand after I finished my 40+ day supply of prilosec otc.

I am certain the prilosec has helped with my sleeping, but I don't want to use it forever. So when this runs out I may try one of the brands you mentioned.

I hope, also to have the time to watch those videos. With a 4 year old around, my screen time is extremely sporadic and I don't know if I can get a block of time that long during the day. Maybe after the whirlwind of activity is in bed!

Jen

[Loveylouise]

I started nexium maybe 3 weeks ago and also raised the head of my bed. Neither seemed to affect my air swallowing. I am trying to not sleep on my right side. One of the presentations discussed the effect of sleep posture, with sleeping on your right side causing the most problems. For 2 nights now, I have not swallowed air. I figured, what comes up, must also go down, so have attempted to not sleep on my right. It seems to be working. Someone else might want to try this simple fix and report in.
Louise

[roster]

....... One of the presentations discussed the effect of sleep posture, with sleeping on your right side causing the most problems. For 2 nights now, I have not swallowed air. ......

Good point Louise. I can't sleep on right or left side without getting bad aerophagia. So I force myself to sleep only on my back. This is not always so easy for me and sometimes I awaken full of air having rolled to one side in my sleep.

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CPAPopedia Keywords Contained In This Post (Click For Definition): aerophagia

[socknitster]

Me too, Rooster, although it would be interesting if I paid more attention to whether it was worse on right vs. left because Louise makes an excellent point--the right side is far worse for digestion than the left.

Sometimes I wake up on my back with a terrible strong urge to roll on my side. I always pay for it within an hour.

Jen

[roster]

...... Being a sufferer of silent gerd myself, I have been taking prilosec otc for the last month. I am reluctant to continue it long term, knowing the side effects snoredog mentioned. The other brands you mentioned, taken with the evening meal might be a good compromise for me. .........

Jen

Hello Jen,

The gastroenterolist told me to take Prevacid daily for six months and then come in for another consultation. He indicated if it helps with GERD/sleep, I may be using it daily the rest of my life. I came home and read the product information for Prevacid and it states that it has only been studied for eight weeks daily usage and that further tests need to be conducted to determine if it causes stomach tumors. OK, so if I take it daily for the rest of my life that may not be so much longer.

Rooster. have you tried sleeping on a wedge? I have been happy with my MedSlat brand wedge from Amazon. It is long enough to reach the hips rather than just the head and shoulders like most wedges on the market. I believe it is 30+ inches long.

I have the head of the bed elevated three inches and also use an eight-inch wedge and a small pillow with a neck roll. My wedge does not reach my hips so there is the concern about bending at the stomach and worsening the GERD effect. I will measure the length of my wedge when I get time and compare it to the MedSlant wedge. Thanks for the tip.

If you ever have the time to watch the lectures, I think you will find them fascinating. Much of what they are presenting is at the hypothesis stage and hopefully they are getting funding to continue studies.

Regards,

Rooster

[socknitster]

yes, prilosec has a similar warning about not using for more than two weeks. Yet they sell it in a 44 dose pack. I asked my ent about this and he said no worries. But then what does he know? I haven't seen a gastro doc but I will be talking about it with my gp who has a minor specialty in gastro. It is a puzzle.

Jen