tag:theconversation.com,2011:/uk/topics/gastric-reflux-8028/articlesgastric reflux – The Conversation2023-01-04T19:20:35Ztag:theconversation.com,2011:article/1932222023-01-04T19:20:35Z2023-01-04T19:20:35Z5 tips to take the best care of your voice for everyone who sings, from a speech pathologist<figure><img src="https://images.theconversation.com/files/500247/original/file-20221212-91737-p3m533.jpg?ixlib=rb-1.1.0&rect=15%2C0%2C5152%2C3445&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>The care of your singing voice is crucial to maintain a healthy and long-life voice. </p>
<p>Professional singers often have teams of people keeping their voices healthy, and they have received lots of training in how to take care of their voice.</p>
<p>But everyone who sings – from young students to passionate amateurs – should be taking care of their voice.</p>
<p>If you are a singer, here are five crucial tips to prevent vocal problems. </p>
<h2>1. Keep hydrated</h2>
<p>Hydration is the most important fact to be considered when singing. </p>
<p>When we are dehydrated, the biomechanical properties of our vocal folds are impacted, decreasing our vocal range and increasing the stress on these folds.</p>
<p>Singers who do not hydrate well are <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2925668/">at risk</a> of developing voice disorders such as nodules and polyps.</p>
<p>An easy way to stay hydrated is to keep up your water consumption. Singers can complement this by using nebulisers and humidifiers.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/500221/original/file-20221211-94733-uu5no9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A woman with her face over a bowl." src="https://images.theconversation.com/files/500221/original/file-20221211-94733-uu5no9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/500221/original/file-20221211-94733-uu5no9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/500221/original/file-20221211-94733-uu5no9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/500221/original/file-20221211-94733-uu5no9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/500221/original/file-20221211-94733-uu5no9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/500221/original/file-20221211-94733-uu5no9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/500221/original/file-20221211-94733-uu5no9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">You can keep your vocal cords hydrated by breathing in steam.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
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</figure>
<p>Humidifiers balance out dry air caused by heating or air conditioning. </p>
<p>Nebulisers assist with hydration directly. By breathing in a saline water solution or purified water, we can see an immediate influence on our vocal folds. </p>
<p>You don’t need fancy equipment. You can also breathe in steam from boiled water. Make sure to be careful with the temperature, as steam can burn our airway when it is too hot. Pour boiled water into a bowl, wait 5-7 minutes, place a towel over your head and then breathe in as many times as you like. </p>
<h2>2. Warm-up and cool-down your voice</h2>
<p>Vocal warm-up and cool-down exercises are <a href="https://www.sciencedirect.com/science/article/pii/S0892199717300176">crucial</a>: these will have a positive benefit on your voice in the moment and prevent future injuries. </p>
<p>An easy warm-up you can try only requires a straw. With a straw between your lips into the air or a cup of water, make a “u” sound. Working for five minutes, change the pitch and frequency of making this sound. The added resistance of singing through a straw will give your vocal folds a good work out.</p>
<p>You can also add resistance by speaking or singing into a CPR mask.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/500564/original/file-20221212-304-26wei2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A CPR mask" src="https://images.theconversation.com/files/500564/original/file-20221212-304-26wei2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/500564/original/file-20221212-304-26wei2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=413&fit=crop&dpr=1 600w, https://images.theconversation.com/files/500564/original/file-20221212-304-26wei2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=413&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/500564/original/file-20221212-304-26wei2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=413&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/500564/original/file-20221212-304-26wei2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=519&fit=crop&dpr=1 754w, https://images.theconversation.com/files/500564/original/file-20221212-304-26wei2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=519&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/500564/original/file-20221212-304-26wei2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=519&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Add resistance by singing through a CRP mask.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
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<p>Other exercises don’t require these materials. You can try lips or tongue trills, humming and blowing raspberries. </p>
<p>While there are many internet tutorials on how to do these exercises, I suggest you practise under professional supervision to avoid damaging your voice by going beyond your vocal limits. </p>
<h2>3. Watch your lifestyle factors</h2>
<p>Lifestyle is fundamental when taking care of our voices.</p>
<p>In order to avoid injuries or develop any voice disorders, we should monitor external factors such as maintaining <a href="https://wp.stolaf.edu/musician-health/nutrition-eating-and-singing/">a balanced diet</a>, having <a href="https://wp.stolaf.edu/musician-health/resting-your-voice/">periods of rest</a> and reducing the consumption of <a href="https://tobaccofreelife.org/resources/smoking-singing/">cigarettes</a>, <a href="https://www.openmicuk.co.uk/advice/alcohol-and-singers/">alcohol</a>, <a href="https://www.openmicuk.co.uk/advice/how-much-can-recreational-drugs-affect-singing/">drugs</a>, <a href="https://www.openmicuk.co.uk/advice/is-coffee-good-or-bad-for-singers/">caffeine</a> and <a href="https://www.openmicuk.co.uk/advice/are-fizzy-drinks-good-or-bad-for-singers/">soft drinks</a>. </p>
<p>By changing these habits, you can preserve good vocal health and keep your body running properly. You can also guard against developing reflux. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/500241/original/file-20221211-95362-4pofku.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A woman drinks a cola." src="https://images.theconversation.com/files/500241/original/file-20221211-95362-4pofku.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/500241/original/file-20221211-95362-4pofku.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=371&fit=crop&dpr=1 600w, https://images.theconversation.com/files/500241/original/file-20221211-95362-4pofku.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=371&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/500241/original/file-20221211-95362-4pofku.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=371&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/500241/original/file-20221211-95362-4pofku.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=466&fit=crop&dpr=1 754w, https://images.theconversation.com/files/500241/original/file-20221211-95362-4pofku.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=466&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/500241/original/file-20221211-95362-4pofku.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=466&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Drinking soft drinks can negatively impact your voice.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<p>Reflux occurs when acids from your stomach travel back up your throat. Symptoms include a burning sensation in your chest (heartburn), backwash (regurgitation) of food or sour liquid, upper abdominal or chest pain, trouble swallowing (dysphagia) or a sensation of a lump in your throat. </p>
<p>This stomach acid can <a href="http://www.healthsystem.virginia.edu/docs/per/diet-tips-for-gastroesophageal-reflux-disease-gerd/handout_view_patient/@@getDocument">dry and irritate</a> your vocal folds. </p>
<p>If you do experience any of these symptoms, keep up your water intake, try to avoid lying down for at least two to three hours after a meal and keep your head elevated using an extra pillow or two while you sleep. </p>
<p>If these symptoms persist, visit your doctor for further examination. </p>
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<p>
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<strong>
Read more:
<a href="https://theconversation.com/explainer-what-is-gastric-reflux-18791">Explainer: what is gastric reflux?</a>
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</p>
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<h2>4. Listen to your body</h2>
<p>Sometimes our body sends signals when struggling. We should pay close attention to what our bodies are telling us.</p>
<p>Negative warning signs can include a reduced tonal range, constant throat clearing, vocal fatigue, pain during or after singing or talking, mild or moderate abdominal tension, unstable voice, pitch breaks, difficulty singing or speaking softly. </p>
<p>Speaking or singing should not present with any negative symptoms or conditions. </p>
<p>It’s important to note home remedies like tea with honey, lemon and ginger, and gargles with salty water – or even alcohol – <a href="https://theconversation.com/how-to-actually-fix-a-lost-voice-according-to-science-hint-lemon-and-honey-doesnt-work-158230">do not</a> fix your voice. These will go directly to the oesophagus and will not have any effect on your vocal folds.</p>
<p>If you are experiencing symptoms like these, pay more attention to things like your warm up, your cool down, periods of rest and your levels of hydration. If they persist, visit a doctor or a speech pathologist.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-to-actually-fix-a-lost-voice-according-to-science-hint-lemon-and-honey-doesnt-work-158230">How to actually fix a lost voice, according to science (hint: lemon and honey doesn't work)</a>
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</em>
</p>
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<h2>5. See a professional</h2>
<p>Don’t try and push through any pain or difficulties you are facing.</p>
<p>When facing any vocal difficulty, you should visit an ear, nose and throat doctor (ENT) or a speech pathologist. </p>
<p>An ENT can check your larynx and other structures to make sure you do not have any organic or functional disorders impacting your voice.</p>
<p>If you would like to practise new techniques – like belting or voice distortions – consult with voice specialists like speech pathologists, vocal coaches or music teachers who are experts on these areas. </p>
<p>Last but not least, check your voice with professionals once a year. This will help with the prevention of future injuries and help you maintain a healthy voice. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/keeping-injured-voices-hush-hush-why-professional-singers-and-actors-often-dont-seek-treatment-for-vocal-illness-183330">Keeping injured voices hush-hush: Why professional singers and actors often don’t seek treatment for vocal illness</a>
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</em>
</p>
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<img src="https://counter.theconversation.com/content/193222/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sandra Rojas is affiliated with Universidad San Sebastián, Santiago, Chile. </span></em></p>Everyone who sings – from young students to passionate amateurs – should be taking care of their voice.Sandra Rojas, Speech pathologist, Voice specialist, Researcher, Federation University AustraliaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1245782019-10-02T06:10:04Z2019-10-02T06:10:04ZWeekly Dose: ranitidine, the heartburn medicine being recalled because of cancer-causing contamination<figure><img src="https://images.theconversation.com/files/295140/original/file-20191002-101488-5qo03y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Ranitidine, which works by either neutralising acid or reducing the production of stomach acid, is available in a range of generic and brand name formulations.</span> <span class="attribution"><span class="source">Author photo</span></span></figcaption></figure><p>Ranitidine is a medicine used for the short-term treatment of heartburn. Available in supermarkets and pharmacies, a prescription is only needed when a higher dose of the medicine is required over a longer period of time. </p>
<p>Ranitidine (sold under brand names Zantac, Rani 2, and Ausran) is currently in the news because regulators have found that most formulations are contaminated with a chemical called NDMA, which is as a probable carcinogen. </p>
<p>The drug has been <a href="https://www.health.harvard.edu/blog/popular-heartburn-drug-ranitidine-recalled-what-you-need-to-know-and-do-2019092817911">recalled by the manufacturers</a> in some countries. Two generic brands – <a href="http://apps.tga.gov.au/PROD/SARA/arn-detail.aspx?k=RC-2019-RN-01455-1">Apotex Ranitidine</a> and <a href="http://apps.tga.gov.au/PROD/SARA/arn-detail.aspx?k=RC-2019-RN-01311-1">Sandoz Ranitidine</a> – have been recalled in Australia so far, with <a href="https://www.tga.gov.au/alert/ranitidine">more recalls likely</a>. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-safe-are-heartburn-medications-and-who-should-use-them-80809">How safe are heartburn medications and who should use them?</a>
</strong>
</em>
</p>
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<h2>When was it developed?</h2>
<p>Ranitidine was first reported in the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2043664/pdf/brjpharm00670-0106.pdf">scientific literature in 1976</a>, and became available in 1981. </p>
<p>Peptic ulcer disease had been a significant health issue affecting millions of people around the world and at the time of ranitidine coming to market, approximately <a href="https://www.ncbi.nlm.nih.gov/pubmed/6378441">four million people</a> in the United States had active peptic ulcers, which resulted in 6,000 deaths per year.</p>
<p>At one stage, ranitidine, as sold under the Zantac brand name, was the <a href="https://www.ncbi.nlm.nih.gov/pubmed/10169076">best selling drug in the world</a>. </p>
<p>However, the drug is now off-patent (available in cheap generic formulations) and is included on the World Health Organisation’s (WHO) <a href="https://www.who.int/medicines/publications/essentialmedicines/18th_EML.pdf">list of essential medicines</a> as an anti-ucler medicine.</p>
<h2>How and why is it used?</h2>
<p>Antacids work by either neutralising acid or reducing the production of stomach acid.</p>
<p>Ranitidine reduces the amount of acid produced in the stomach and is part of a larger family of drugs called H2-histamine receptor antagonists.</p>
<p>It is a type of antihistamine, but not the type used for treating allergies. This is because the chemical <a href="https://medlineplus.gov/medlineplus-videos/histamine-the-stuff-allergies-are-made-of/">histamine</a>, although involved in allergic reactions, also stimulates the production of stomach acid. So blocking the effect of histamine also reduces the production of stomach acid. </p>
<p>Ranitidine is commonly used to relieve the symptoms of heartburn and indigestion but has also been used in the past to treat more serious conditions, such as peptic ulcers. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/295166/original/file-20191002-101479-4jq60i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/295166/original/file-20191002-101479-4jq60i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/295166/original/file-20191002-101479-4jq60i.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/295166/original/file-20191002-101479-4jq60i.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/295166/original/file-20191002-101479-4jq60i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/295166/original/file-20191002-101479-4jq60i.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/295166/original/file-20191002-101479-4jq60i.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Ranitidine reduces the amount of acid produced in the stomach.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/1131953912?src=nxBHufddmHLG8QIOSiHXsg-1-16&size=huge_jpg">Dragana Gordic/Shutterstock</a></span>
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<p>In recent times, longer lasting medications called proton pump inhibitors, that are more effective at reducing acid production, have largely replaced ranitidine for more serious conditions. </p>
<p>The most common formulations of ranitidine sold in pharmacies are oral tablets. For those patients who have difficulty swallowing, the medicine is also available as effervescent tablets (fast dissolving in a glass of water) and as a pre-prepared oral liquid.</p>
<h2>What’s the link with cancer?</h2>
<p>Ranitidine is currently in the news after the Australian Therapeutic Goods Administration (TGA) <a href="https://www.tga.gov.au/alert/ranitidine">issued an alert</a> stating many formulations of the drug were contaminated with a chemical called <em>N</em>-nitrosodimethylamine, abbreviated as NDMA. This should not be confused with the illegal party drug <a href="https://www.healthdirect.gov.au/mdma-ecstasy">MDMA (ecstasy)</a>, which is a completely different chemical. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/weekly-dose-ecstasy-the-party-drug-that-could-be-used-to-treat-ptsd-55149">Weekly Dose: ecstasy, the party drug that could be used to treat PTSD</a>
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</em>
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<p>Similar alerts have been issued by the US <a href="https://www.fda.gov/news-events/press-announcements/statement-alerting-patients-and-health-care-professionals-ndma-found-samples-ranitidine">Food and Drug Administration</a>, and <a href="https://healthycanadians.gc.ca/recall-alert-rappel-avis/hc-sc/2019/71029a-eng.php">Health Canada</a>.</p>
<p>Contamination of ranitidine formulations is a problem because the World Health Organisation lists NDMA as a <a href="https://www.who.int/water_sanitation_health/dwq/chemicals/ndmasummary_2ndadd.pdf">probable carcinogen</a>, meaning it may cause cancer. </p>
<p>But it’s important to note most people are exposed to NDMA as part of their normal lives. NDMA can be found in cooked and smoked meats, from smoking cigarettes, beer, and even some toiletry and cosmetic products. </p>
<p>It’s not clear how the ranitidine formulations have become contaminated with NDMA. A similar chemical, dimethylamine, is used in the synthesis of ranitidine, and it may be possible some NDMA is created when the drug is made. Alternatively, ranitidine may be broken down, producing NDMA, during storage. </p>
<p>It will be important to determine the source of the contamination if new formulations are to be made free from NDMA.</p>
<p>The response in many countries has been the recall of ranitidine formulations. In the United States, the companies Sandoz and Apotex have voluntarily withdrawn their brands from sale. In Canada, the government has asked companies to stop distributing the medicine. </p>
<p>On September 17, Australia’s <a href="https://www.tga.gov.au/alert/ranitidine">TGA said it anticipated a recall of ranitidine</a> and until then would be working with international regulators and companies to investigate the problem. The TGA also announced it was doing batch testing of products to determine the extent of the contamination in Australia. </p>
<p>Since that announcement two products have been recalled, <a href="http://apps.tga.gov.au/PROD/SARA/arn-detail.aspx?k=RC-2019-RN-01455-1">Apotex Ranitidine</a> and <a href="http://apps.tga.gov.au/PROD/SARA/arn-detail.aspx?k=RC-2019-RN-01311-1">Sandoz Ranitidine</a>, but further recalls and shortages may occur.</p>
<h2>What if you’re currently taking ranitidine?</h2>
<p>If the medicine works for you and you wish to keep taking it, there is <a href="https://www.tga.gov.au/alert/ranitidine">no immediate health risk</a>. The only issue is from long-term use and could mean a possible increase in your risk of cancer later in life. </p>
<p>If you do wish to stop taking ranitidine, your pharmacist or general practitioner will be able to recommend other heartburn medicines that may be effective for you.</p><img src="https://counter.theconversation.com/content/124578/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Associate Professor Wheate in the past has received funding from the ACT Cancer Council, Tenovus Scotland, Medical Research Scotland, Scottish Crucible, and the Scottish Universities Life Sciences Alliance. He is Fellow of the Royal Australian Chemical Institute and a member of the Australasian Pharmaceutical Science Association.</span></em></p><p class="fine-print"><em><span>Andrew Bartlett is a member of the Australian College of Pharmacy</span></em></p>Contamination with the chemical NDMA means long-term use of ranitidine may increase a person’s risk of cancer later in life.Nial Wheate, Associate Professor | Program Director, Undergraduate Pharmacy, University of SydneyAndrew Bartlett, Associate Lecturer Pharmacy practice, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/808092017-08-10T02:03:26Z2017-08-10T02:03:26ZHow safe are heartburn medications and who should use them?<figure><img src="https://images.theconversation.com/files/181142/original/file-20170807-19163-5a5hkt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Many people take heartburn medications for longer than they should. </span> <span class="attribution"><span class="source">from www.shutterstock.com.au</span></span></figcaption></figure><p>Many people suffer regularly from heartburn - a burning feeling in the chest caused by stomach acid travelling up the food pipe (oesophagus) after eating. This causes inflammation and irritation of the lower oesophagus, and also ulcers. The most commonly prescribed medications to treat what is known as gastro-oesphageal reflux disease, are “proton pump inhibitors”.</p>
<p>Proton pump inhibitors (known in Australia by names such as Nexium, Pariet, Losec, Somac and Zoton) work by preventing key pumps in the cells of the stomach that produce stomach acid from working. In stopping the production of stomach acid they help to reduce the inflammation and heal ulcers caused by the stomach acid. </p>
<p>Often people on these medications will take them for years. But recent reports of dangerous side effects and <a href="http://bmjopen.bmj.com/content/7/6/e015735">even early death</a> have led some to question whether this is the right medication for them.</p>
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<strong>
Read more:
<a href="https://theconversation.com/explainer-what-is-gastric-reflux-18791">Explainer: what is gastric reflux?</a>
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</p>
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<h2>How effective are heartburn medications?</h2>
<p>The treatment of reflux disease is the most common reason proton pump inhibitors are prescribed. Reflux disease can be broadly classified into two types, once your stomach and oesophagus have been examined with a thin, flexible camera (<a href="https://www.hindawi.com/journals/isrn/2012/391631/">gastroscopy</a>).</p>
<p>The first type is oesophagitis where there are clear erosions or swelling in the lower oesophagus indicative of acid damage. The other is non-erosive reflux disease, where there is no visible damage in the lower oesophagus from acid, but the patient still experiences reflux symptoms such as heartburn.</p>
<p>A study found these drugs were very effective for treating reflux disease, with eight weeks of therapy with standard (once daily) dosing healing acid damage in <a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003244.pub2/abstract;jsessionid=9BE0E698905FE22344278844E373F08C.f03t02">more than 80% of patients</a>.</p>
<p>Even for the non-erosive type of the disease, heartburn medication can be beneficial. An <a href="https://www.nature.com/articles/srep32126">analysis of studies in this area</a> found all of the different proton pump inhibitors at a dose of more than 5mg daily were effective in significantly improving symptoms in non-erosive reflux disease.</p>
<p>These drugs are also good at healing stomach ulcers. For patients on non-steroidal anti-inflammatory drugs (NSAIDs) such as aspirin, proton pump inhibitors <a href="https://www.ncbi.nlm.nih.gov/pubmed/2643037">have been shown to be more effective</a> than other drugs in healing stomach ulcers. </p>
<h2>How safe are they?</h2>
<p>A <a href="http://bmjopen.bmj.com/content/7/6/e015735">recent study</a> followed 350,000 US veterans for more than five years and found a small increased risk of early death in those taking this kind of medication.</p>
<p>The study was well designed but could not completely eliminate other medical factors that could potentially be occurring in the study subjects. The risk of death was noted to increase the longer patients used proton pump inhibitors.</p>
<p>The relative risk for death was high when comparing two groups (those on the proton pump inhibitor versus those on a different medication) against each other. However the actual or absolute risk increase for death (0.2% per year) was small in the study. </p>
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Read more:
<a href="https://theconversation.com/what-you-need-to-know-to-understand-risk-estimates-67643">What you need to know to understand risk estimates</a>
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<p>This means, overall, there are more benefits to being on a proton pump inhibitor to heal severe reflux damage, heal a bleeding gastric ulcer or to prevent oesophageal cancer in the presence of other conditions (Barrett’s oesophagus is a precancerous condition caused by long-term acid damage) than not being on the medication. </p>
<p>But the authors acknowledge the need to be careful about long-term use of proton pump inhibitors and to make sure they are indeed prescribed for a proper medical reason.</p>
<p>This study was just one of many safety concerns relating to long-term use of these drugs. But the majority of available data on safety are derived from studies that look at past data and <a href="http://jamanetwork.com/journals/jama/fullarticle/199672">don’t fully take into account</a> other medical conditions the study subjects might’ve had, or <a href="https://www.ncbi.nlm.nih.gov/pubmed/21318590">prove that the medications</a> actually caused any negative reported side <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3090435/">effects</a>.</p>
<p>There is <a href="https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-017-0804-x">strong evidence</a> proton pump inhibitors cause fundic gland polyps that are common benign lumps at the top part of the stomach. These are not dangerous. Proton pump inhibitor use can also lead to vitamin B12 deficiency. This is unlikely to affect your health provided the detected low vitamin B12 levels are corrected.</p>
<p>The development of a kidney injury called “acute interstitial nephritis” is also significantly linked to use of these <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3741979/">drugs</a> but fortunately this is a very rare event. This condition very often improves once the drugs are stopped early.</p>
<p>There are reported adverse events that are weakly associated with the drug, although a review by international experts found the drug is a likely <a href="https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-016-0718-z">cause</a>. These include bacterial overgrowth in the bowel, an infection of abdominal fluid (spontaneous bacterial peritonitis) in patients with liver cirrhosis, an infection from an organism called <em>Clostridium difficile</em>, iron deficiency and magnesium deficiency.</p>
<p>There are a number of reported adverse events with weak associations that are currently unproven to be caused by these drugs. These include bone fractures, chronic kidney disease, dementia, myocardial infarction (a blockage of blood flow to the heart muscle) and <a href="https://www.nature.com/nrgastro/journal/v13/n5/full/nrgastro.2016.44.html">pneumonia</a>.</p>
<p>When the long-term safety of proton pump inhibitors was <a href="http://onlinelibrary.wiley.com/doi/10.1111/apt.13194/full">compared to anti-reflux surgery in randomised trials</a>, there was no difference in negative side effects (however survival itself wasn’t examined). Further well-designed clinical trials are underway to help provide more of a definitive answer on the issue of safety. </p>
<h2>So how should they be used?</h2>
<p>Proton pump inhibitors are widely prescribed drugs and in many countries are available over the counter. Evidence suggests that up to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2174763/">70% of use may be inappropriate</a>. Medically appropriate reasons for taking these drugs long-term include Barrett’s oesophagus, severe oesophagitis and in cases where there is a high risk of <a href="https://www.primaryhealthtas.com.au/sites/default/files/A%20Guide%20to%20Deprescribing%20Proton%20Pump%20Inhibitors.pdf">gastrointestinal bleeding</a>.</p>
<p>Once these drugs are prescribed they’re rarely deprescribed. Patients can remain on them for many years, often without the initial medical reason for prescribing being revisited.</p>
<p>Proton pump inhibitors should only be taken when medically appropriate, and for as short a time as possible. In the case of non-erosive reflux disease, dosages <a href="http://www.gastrojournal.org/article/S0016-5085(01)38032-0/fulltext">can be successfully reduced</a> and even withdrawn in the majority of patients over time. When the drug is stopped, <a href="https://www.primaryhealthtas.com.au/sites/default/files/A%20Guide%20to%20Deprescribing%20Proton%20Pump%20Inhibitors.pdf">recurrence of symptoms</a> should be monitored. </p>
<p>If ongoing use of a proton pump inhibitor is required in reflux disease for symptom relief then it should be used at the lowest dose or as required. But overall, the benefits of proton pump inhibitors outweigh the potential risks in most patients that have a relevant and appropriate medical need.</p><img src="https://counter.theconversation.com/content/80809/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Vincent Ho does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Recent reports of dangerous side effects and even early death from heartburn medications have led some to question whether this is the right medication for them.Vincent Ho, Lecturer and clinical academic gastroenterologist, Western Sydney UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/633192016-09-21T20:27:36Z2016-09-21T20:27:36ZWhat is infant reflux and will it get better?<figure><img src="https://images.theconversation.com/files/134369/original/image-20160817-13707-4pkjkr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Why can't babies easily keep their food down like we can?</span> <span class="attribution"><span class="source">from www.shutterstock.com.au</span></span></figcaption></figure><p>Gastro-oesophageal reflux is a condition that affects up to <a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008550.pub2/abstract">half</a> of all babies <a href="http://adc.bmj.com/content/early/2015/03/09/archdischild-2014-306232">under three months of age</a>. </p>
<p>It can happen multiple times a day, particularly after feeds. It happens when food is swallowed into the stomach, but then regurgitates back into the oesophagus (food pipe). Sometimes it then drops back into the stomach (and down the gastrointestinal tract) or sometimes it washes back up to the mouth or further, causing a vomit or spill of feed.</p>
<h2>Why do so many babies get reflux?</h2>
<p>When we swallow food, multiple factors usually combine to keep it in the stomach.</p>
<p>First, people generally sit up to eat, so gravity assists the food staying down.</p>
<p>Second, we usually eat food with enough weight and density to stay in the stomach. </p>
<p>Third, we have a lower oesophageal sphincter, which is a muscular band around the lower end of the oesophagus, helping stop food coming back up. </p>
<p>Fourth, our oesophagus is quite long, helping to increase the distance food would have to travel to come back up.</p>
<p>In babies, these factors are <a href="http://www.ncbi.nlm.nih.gov/pubmed/19445547">not there</a>. They lie down most of the time, consume only liquid, their muscles are not yet as well developed as they will become, and their oesophagus is still relatively short. As a result, babies are far more likely to have some degree of regurgitation of their milk.</p>
<p>Reflux isn’t necessarily a bad thing for babies. If they have swallowed a large amount of milk (and air) during a feed, reflux is a way the body can help to <a href="http://www.ncbi.nlm.nih.gov/pubmed/16278060">reduce the pressure</a>, and relieve the discomfort of an overfull stomach. </p>
<h2>What are the symptoms?</h2>
<p>Reflux happens very commonly in babies, and many <a href="https://www.nice.org.uk/guidance/ng1/resources/gastrooesophageal-reflux-disease-in-children-and-young-people-diagnosis-and-management-51035086789">don’t show any symptoms</a>. </p>
<p>The most common symptom of reflux is a small spill of milk after a feed. Sometimes when the milk mixes with stomach acid then washes back up the oesophagus, the resulting regurgitation causes pain. </p>
<p>Other <a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008550.pub2/abstract">symptoms</a> may include distress or discomfort with feeds, crying during or after feeds or more significant vomiting with feeds. Some babies will refuse or vomit so much of their feed they are unable to gain weight. Some even lose weight. </p>
<p>It’s important to bear in mind many of these symptoms can be caused by issues <a href="http://www.ncbi.nlm.nih.gov/pubmed/16278060">other than reflux</a> such as <a href="http://theconversation.com/my-baby-is-crying-is-it-colic-how-can-i-help-62952">colic</a>, cow’s milk protein intolerance, infections and underlying <a href="http://adc.bmj.com/content/early/2015/03/09/archdischild-2014-306232">gastrointestinal</a> disorders. A medical review is useful to help look for any other causes prior to making a diagnosis of reflux.</p>
<p><a href="https://www.nice.org.uk/guidance/ng1/resources/gastrooesophageal-reflux-disease-in-children-and-young-people-diagnosis-and-management-51035086789">Silent reflux</a> is usually used to describe a baby who is regurgitating a meal into the oesophagus but not as far as the mouth. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/134370/original/image-20160817-13678-1unhban.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/134370/original/image-20160817-13678-1unhban.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/134370/original/image-20160817-13678-1unhban.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=896&fit=crop&dpr=1 600w, https://images.theconversation.com/files/134370/original/image-20160817-13678-1unhban.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=896&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/134370/original/image-20160817-13678-1unhban.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=896&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/134370/original/image-20160817-13678-1unhban.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1126&fit=crop&dpr=1 754w, https://images.theconversation.com/files/134370/original/image-20160817-13678-1unhban.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1126&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/134370/original/image-20160817-13678-1unhban.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1126&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Reflux is only a problem if it’s causing the baby distress or they’re not getting enough of their feed to grow.</span>
<span class="attribution"><span class="source">from www.shutterstock.com</span></span>
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<p>It can still lead to discomfort and distress, but doesn’t cause a vomit or a spill of milk. In this way, it can be difficult for a parent to identify the cause of the distress.</p>
<h2>Treatment</h2>
<p>Usually reflux in babies is <a href="https://www.nice.org.uk/guidance/ng1/resources/gastrooesophageal-reflux-disease-in-children-and-young-people-diagnosis-and-management-51035086789">not</a> something that needs extra tests or treatment, because it doesn’t usually cause significant problems, and the symptoms <a href="http://adc.bmj.com/content/early/2015/03/09/archdischild-2014-306232">go away</a> by themselves. </p>
<p>This is because the particular features of babies which cause reflux (lying down, consuming only liquid, having relatively underdeveloped muscles and a shorter oesophagus) improve with time. Additionally, some of the treatments themselves can be harmful or may not work.</p>
<p>Lots of different <a href="http://adc.bmj.com/content/early/2015/03/09/archdischild-2014-306232">medications</a> have been trialled for reflux. In general, they’re <a href="https://www.nice.org.uk/guidance/ng1/resources/gastrooesophageal-reflux-disease-in-children-and-young-people-diagnosis-and-management-51035086789">only recommended</a> for babies with poor weight gain or significant distress, as well as regurgitation. They’re not generally recommended as their effects <a href="http://www.sciencedirect.com/science/article/pii/S0022347614011056">have been found to be poor</a> on <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2907988/">simple regurgitation.</a> They also tend to have some <a href="http://www.bmj.com/content/341/bmj.c4420">side effects</a> including chest infections, abdominal pain and vomiting – the very symptoms they are used to prevent. </p>
<p>Alginate substances made for babies (such as <a href="https://www.nice.org.uk/guidance/ng1/resources/gastrooesophageal-reflux-disease-in-children-and-young-people-diagnosis-and-management-51035086789">gaviscon infant</a>) work by thickening the feed and forming a <a href="http://www.bmj.com/content/341/bmj.c4420">coating</a> over the lower oesophagus and stomach. These can help with some symptoms. They contain a relatively high amount of salt, so should only be used after consulting with a doctor. It should also <a href="http://www.bmj.com/content/341/bmj.c4420">not</a> be used with formula thickeners. </p>
<p>Some <a href="http://www.bmj.com/content/341/bmj.c4420">formula thickeners</a> may help in bottle-fed babies. Thicker feeds encourage the milk to stay down in the stomach and make it harder to wash back up the oesophagus. But, thicker feeds can be harder for a baby to suck and swallow, and can affect the nutritional content of the formula. Similarly, reducing the volume of feeds might reduce <a href="https://www.nice.org.uk/guidance/ng1/resources/gastrooesophageal-reflux-disease-in-children-and-young-people-diagnosis-and-management-51035086789">reflux</a>, but may also impact on the nutrition and growth of a baby. The number of feeds in a day may need to be increased if the volume of each feed is reduced. </p>
<p>While there are some surgical options, these are usually reserved for older children with severe reflux or those with <a href="https://www.nice.org.uk/guidance/ng1/resources/gastrooesophageal-reflux-disease-in-children-and-young-people-diagnosis-and-management-51035086789">complications</a>. </p>
<p>Treatment without medication can be effective. This includes letting a baby lie prone (tummy down) or on their left side while still awake and settling after a meal, provided they are supervised. <em><a href="https://www.nice.org.uk/guidance/ng1/resources/gastrooesophageal-reflux-disease-in-children-and-young-people-diagnosis-and-management-51035086789">Never</a></em> let a baby sleep in these positions, as they are associated with an <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2907988/">increased risk</a> of SIDS (sudden infant death syndrome). </p>
<p>Complications of reflux in babies are <a href="http://adc.bmj.com/content/early/2015/03/09/archdischild-2014-306232">rare</a>. They are more likely in premature babies (who have more immature bodies), and in babies with other <a href="https://www.nice.org.uk/guidance/ng1/resources/gastrooesophageal-reflux-disease-in-children-and-young-people-diagnosis-and-management-51035086789">significant health concerns</a>. </p>
<p>With excessive vomiting, babies can have difficulty gaining weight. Frequent regurgitation of stomach acid can occasionally cause trauma to the oesophagus. Some of the milk can wash into the trachea (windpipe), causing breathing difficulty or infection. </p>
<h2>Does it ever go away?</h2>
<p>Very few babies (<a href="http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008550.pub2/abstract">less than 5%</a>) with reflux have any ongoing symptoms by the time they are around one year old.</p>
<p>In the meantime, make sure your baby’s weight is being monitored and a health professional has assessed your baby to ensure the most likely diagnosis is reflux. Be aware that while very common, reflux goes away with time, and becomes less frequent with time. Further treatment and tests are not usually helpful. </p>
<p>A one- to two-week trial of feed thickener for bottle-fed babies or infant alginate preparations for breast-fed babies may have some effect, but only if suggested by your doctor. Don’t persist with these if your baby doesn’t improve. </p>
<p>Other medications are only advisable if your baby has particular other signs and should be prescribed at the discretion of a medical professional. Practical measures such as letting a baby lie on their tummy while awake and supervised after a meal may offer some improvement, so long as the baby is never allowed to sleep in this position.</p><img src="https://counter.theconversation.com/content/63319/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kirsten Thompson does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Why do babies get reflux more than children and adults? Do any treatments work?Kirsten Thompson, Senior clinical lecturer, The University of Western AustraliaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/525702015-12-31T09:54:15Z2015-12-31T09:54:15ZFestive heartburn cures: why over-the-counter drugs may be hurting your gut<figure><img src="https://images.theconversation.com/files/106721/original/image-20151219-27887-mryw6l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Acid busting PPIs may have some downsides.</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-109674029/stock-photo-adult-man-suffering-from-severe-heartache.html?src=0ot_yFfFh-LlMAS9LoILWg-1-34">Acid by Shutterstock</a></span></figcaption></figure><p>At the time of Xmas parties many of us may be waking up with regrets, sore heads, fragile stomachs and some heartburn (acid reflux) which in a year can affect <a href="http://www.ncbi.nlm.nih.gov/pubmed/9136821">over 40% of us and one in five weekly</a>.</p>
<p>In the past, we may have put up with the symptoms but it is increasingly common to now pop an indigestion tablet. These used to just be some form of milk or alkali but have become much more sophisticated. Proton pump inhibitors (PPIs with names that end in –ozole, such as omeprazole) are drugs that suppress the production of gastric acid. They are able to cause rapid and dramatic reductions in gastric acid and are generally considered to be safe and have few side effects. As a result, they provide effective treatment for a range of gastrointestinal disorders including indigestion, gastroesophageal reflux and stomach ulcers. </p>
<p>They are one of the most widely used medications in the world with <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3388523/">around 12%</a> of the population having used them, and they are consistently among the top ten most profitable drug classes. In Europe and the US, they can be bought without a medical prescription and in the UK are now available in shops and supermarkets.</p>
<p>While they are generally considered safe, recent population studies have highlighted an increased risk of bacterial infection within PPI users. These include infections such as bacterial pneumonia and, most notably, <a href="http://www.ncbi.nlm.nih.gov/pubmed/22710578">an increased risk</a> of <em>Clostridium difficile</em> infection, which can cause severe diarrhoea and is normally associated with antibiotic use.</p>
<p>A <a href="http://gut.bmj.com/content/early/2015/12/30/gutjnl-2015-310861.full">new paper</a> published in Gut by Matthew Jackson from our team at King’s College London, has uncovered a previously neglected side effect of proton pump inhibitors that may explain how they increase users’ risk of getting a bacterial infection. </p>
<h2>Twin stools</h2>
<p>Looking at data from the stool samples of over 1,800 British twins we found that individuals who had used PPIs had different bacteria inhabiting their gut than those who had not. More specifically, PPI users were found to have an increase in their guts of bacteria that would be more likely to inhabit the mouth and skin, such as Streptococcus. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/106722/original/image-20151219-27875-p99rf9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/106722/original/image-20151219-27875-p99rf9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/106722/original/image-20151219-27875-p99rf9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/106722/original/image-20151219-27875-p99rf9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/106722/original/image-20151219-27875-p99rf9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/106722/original/image-20151219-27875-p99rf9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/106722/original/image-20151219-27875-p99rf9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Streptococcus: not so common in the gut.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-295214135/stock-photo-streptococci-spherical-bacteria-on-the-surface-of-skin-or-mucous-membrane-model-of-staphylococcus.html?src=OsqwLwZ7z9a2oDvWt1O9Nw-1-0">Bacteria by Shutterstock</a></span>
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</figure>
<p>These differences were confirmed when we compared the gut bacteria between identical twins where only one twin was using PPIs. Drug use appeared to be the cause rather than the consequence as a number of the bacterial changes over time were replicated in healthy volunteers who were followed up after being given PPIs.</p>
<p>Coincidentally, a second group from the University of Groningen in the Netherlands published <a href="http://gut.bmj.com/content/early/2015/12/09/gutjnl-2015-310376.short?rss=1">almost identical findings</a> at the same time. They too observed changes in the same types of bacteria, and showed an increase of oral species within the gut of PPI users. They also propose that within a population the added infection risks posed by PPI use could outweigh the benefits of PPI use if you factor in increased antibiotic use.</p>
<p>The microbe changes observed by both studies match bacterial alterations in mice that predispose to a nasty and often fatal <em>Clostridium difficile</em> infection, suggesting that the alterations to gut bacteria caused by PPI use in humans <a href="http://mbio.asm.org/content/6/4/e00974-15">could cause</a> the observed increases in bacterial infections. There may also be further health consequences waiting to be uncovered <a href="http://www.ncbi.nlm.nih.gov/pubmed/26488896">such as increased cancer</a> and <a href="http://www.ncbi.nlm.nih.gov/pubmed/26462494">fracture risk</a>. </p>
<p>The study of the bacterial communities inside us is a rapidly evolving field and it is becoming evident that microbes have a much more important and wide-ranging role in human health than previously thought.</p>
<h2>Overused</h2>
<p>PPIs are generally known and marketed to be very safe drugs. Importantly they are very helpful to treat certain conditions such as stomach ulcers and inflammation of the stomach caused by increased acid levels. However, there is evidence from other studies that they are often used when they <a href="http://www.ncbi.nlm.nih.gov/pubmed/22778788">are not clearly needed</a>. Large population studies <a href="http://www.tandfonline.com/doi/abs/10.1586/ecp.12.20?journalCode=ierj20">have shown</a> a slight increased risk of bacterial infections with these drugs, particularly targeting older, frailer people. Our data indicates that PPIs alter the gut flora, allowing bacteria residing in the mouth and nose to displace the normal gut ones. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/106723/original/image-20151219-27897-laogbg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/106723/original/image-20151219-27897-laogbg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/106723/original/image-20151219-27897-laogbg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/106723/original/image-20151219-27897-laogbg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/106723/original/image-20151219-27897-laogbg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/106723/original/image-20151219-27897-laogbg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/106723/original/image-20151219-27897-laogbg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A time of indulgence – but are there other ways to treat heartburn?</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-331940009/stock-photo-people-eating-roasted-chicken-and-drinking-red-wine-at-christmas-dinner.html?src=ZRwsBaNAQVHEafzxQ9tc2Q-1-35">Christmas lunch by Shutterstock</a></span>
</figcaption>
</figure>
<p>We would caution against people stopping PPIs without good discussion with their prescriber, but doctors and patients should be aware of the potential risks and ensure that they are not taking medicines for longer than they need to be – and as always the balance of risks and benefits is different for every individual.</p>
<h2>Safer options?</h2>
<p>The study looked at all brands of PPIs available in the UK. Possible alternative options would depend on why a person is using the drug. Some people are on PPIs to protect against possible future ulcers because of another medication. Generally their risk of an ulcer will depend on their past history and other factors, and they may not need the drug at all. If they are using PPIs because of symptoms of heartburn, then it may be a good idea to explore lifestyle factors and try to identify the exact cause of their symptoms with a doctor. </p>
<p>This research has highlighted a previously neglected side effect of one of the most widely used drugs in the world. The results resemble those of antibiotics which were previously thought to be “safe” but also have devastating effects on our gut microbes and health and are massively over-prescribed. It is time we assessed all our drugs, not only for their effect on our health – but on our 100 trillion gut microbes, too. In the meantime, after a rough night, instead of reaching for your PPI maybe try something microbe-friendly first.</p><img src="https://counter.theconversation.com/content/52570/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Tim Spector is Director of the British Gut microbiome project. He is author of The Diet Myth, a book on gut microbes.</span></em></p><p class="fine-print"><em><span>Claire Steves currently receives funding from the Chronic Disease Research Foundation and the MRC.</span></em></p>PPI drugs are widely used to suppress gastric acid, but they could come with some risk to our 100 trillion gut microbes.Tim Spector, Professor of Genetic Epidemiology, King's College LondonClaire Steves, Clinical Senior Lecturer, King's College LondonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/396302015-10-05T02:58:17Z2015-10-05T02:58:17ZHealth Check: is it OK to chew or crush your medicine?<figure><img src="https://images.theconversation.com/files/93740/original/image-20150903-8793-7669e2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Look for a warning on the box before you attempt to crush or chew tablets, or cut capsules open.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/ephotography29/3176179860/">Erin/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span></figcaption></figure><p>Some people are incapable of swallowing tablets because of physical reasons, such as surgery or gastric reflux, while others struggle for psychological reasons. What can these people do when the doctor prescribes a drug that comes in tablet form? </p>
<p>The standard tablet is designed to be swallowed whole. Once in the stomach, it absorbs water, which causes it to swell and break apart. As it breaks apart, the drug dissolves over a predictable period of time, gets absorbed into the bloodstream and moves around the body.</p>
<p>Some people end up chewing tablets or crushing them up and mixing them with their food, but this can sometimes cause the medicine to not work properly. In some cases, ingesting a crushed tablet can even result in death.</p>
<h2>Important clues</h2>
<p>For a number of reasons some tablets shouldn’t be crushed or chewed. Most importantly, doing so may result in <a href="http://www.pharmainfo.net/tegkmurthy/blog/dose-dumping-technical-perspective">dose dumping</a>; this is when the body very quickly absorbs a large amount of a drug. One consequence of dose dumping is an overdose of the drug, which can lead to death.</p>
<p>Some tablets also come with a special protective layer, called an <a href="http://www.drugs.com/dict/enteric-coated-tablet.html">enteric coating</a>, which is designed to stop it from breaking apart in the stomach. The coating ensures the tablet disintegrates in the small intestine instead. If you chew an enterically coated tablet, the drug will not be absorbed properly and the medicine may be ineffective.</p>
<p>Tablets designed to be chewed have this indicated on their packaging. This is common for drugs designed for young children and certain types of tablets such as multivitamins. </p>
<p>Some medicines are also specifically made into a chewable form, such as some <a href="http://www.empr.com/bayer-chewable/drug/4006/">aspirin tablets</a> and <a href="http://www.mylanta.com/mylanta-gas-maximum-strength-chewable-tablets.html">certain antacids</a>. These are common medicines that may be taken on a regular basis, and by people known to have trouble swallowing tablets.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/93741/original/image-20150903-8827-1x0sm3c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/93741/original/image-20150903-8827-1x0sm3c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=402&fit=crop&dpr=1 600w, https://images.theconversation.com/files/93741/original/image-20150903-8827-1x0sm3c.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=402&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/93741/original/image-20150903-8827-1x0sm3c.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=402&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/93741/original/image-20150903-8827-1x0sm3c.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=505&fit=crop&dpr=1 754w, https://images.theconversation.com/files/93741/original/image-20150903-8827-1x0sm3c.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=505&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/93741/original/image-20150903-8827-1x0sm3c.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=505&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The packaging of most medicines has a printed warning if they shouldn’t be chewed.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/27384147@N02/5043343366/">Ano Lobb/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
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</figure>
<p>The packaging of most other medicines will have a printed warning if the tablets shouldn’t be chewed or crushed. A warning sticker may be placed on the box by the pharmacist when she dispenses the medicine, or the instructions on the back of the box will state that the medicine should not be crushed. </p>
<p>The same rules apply for capsules and caplets. Look for a warning on the box before you attempt to chew them or cut them open. But this applies only to the solid forms of capsules. If you’re taking a <a href="http://www.health.com/health/gallery/0,,20397664_2,00.html">gelcap</a> formulation (a soft, liquid-filled tablet), then it’s never all right to chew or cut it open. And if you’re in any doubt, ask your pharmacist as she’ll be able to give you a definitive answer.</p>
<h2>The alternatives</h2>
<p>If you aren’t able to swallow tablets and your doctor has just prescribed you a medicine that comes in a tablet or capsule formulation, then it’s worthwhile asking your pharmacist whether she can provide the medicine in a different form.</p>
<p>Compounding pharmacies can make their own formulations of some drugs. It may be possible for them to dispense the medicine to you as a solution, syrup or an <a href="http://en.wikipedia.org/wiki/Elixir">elixir</a>, which are all liquid medicine formulations. And if you’re up for something different, they may be able to formulate a <a href="http://en.wikipedia.org/wiki/Suppository">suppository</a> for you.</p>
<p>Suppositories are drug formulations designed to be placed in the rectum. Instead of disintegrating like a tablet does in the stomach, a suppository is designed to melt and release the drug. Most suppositories are made from the same fats and oils found in chocolate, which cause the suppositories to melt when placed in the body. </p>
<p>A suppository is useful for people who can’t swallow tablets for any number of reasons. These may include normal adult patients, but they’re particularly useful for babies, people with swollen throats or severe nausea, or anyone who is unconscious. </p>
<p>What you need to remember is that if you have difficulty swallowing tablets, check the medicine box and ask your pharmacist whether it would be all right to chew or crush your medicine. Much of the time, this will be fine. If it’s not, ask your pharmacist if she can provide an alternative formulation.</p><img src="https://counter.theconversation.com/content/39630/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nial Wheate does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Some people are incapable of swallowing tablets because of physical or psychological reasons. What should they do when the doctor prescribes a drug that comes in tablet form?Nial Wheate, Senior Lecturer in Pharmaceutics, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/187912013-11-19T19:15:15Z2013-11-19T19:15:15ZExplainer: what is gastric reflux?<figure><img src="https://images.theconversation.com/files/35480/original/7pjc28cz-1384749710.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Gastric reflux is brought on by spicy and acidic food and drink, alcohol and overeating.</span> <span class="attribution"><span class="source">Image from shutterstock.com</span></span></figcaption></figure><p>If you’re prone to gastric reflux, you’ll probably be watching closely what you eat and drink during the pre-Christmas party season. You’re certainly not alone; modern, heavy eating habits and a rise in obesity mean the condition is more common than ever, affecting nearly <a href="http://gut.bmj.com/content/early/2013/07/12/gutjnl-2012-304269.full.pdf">three in every ten people</a> worldwide. </p>
<p>Gastric reflux, commonly referred to as heartburn or indigestion, leaves sufferers with a painful burning sensation in the stomach or behind the breastbone and is often coupled with regurgitation. </p>
<p>There are various types of <a href="http://www.ncbi.nlm.nih.gov/pubmed/23899284">gastro-oesophageal disease</a>, as reflux is clinically known, which vary in the degree of damage to the inner lining of the oesophagus and the level of pain experienced. </p>
<h2>Causes</h2>
<p>First, some basics. The oesophagus is the tube which connects the throat to the stomach; between the stomach and oesophagus is a valve or “sphincter” which prevents the backflow of stomach contents – the acid that aids digestion. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/35477/original/fm992zqd-1384749394.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/35477/original/fm992zqd-1384749394.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/35477/original/fm992zqd-1384749394.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=415&fit=crop&dpr=1 600w, https://images.theconversation.com/files/35477/original/fm992zqd-1384749394.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=415&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/35477/original/fm992zqd-1384749394.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=415&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/35477/original/fm992zqd-1384749394.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=522&fit=crop&dpr=1 754w, https://images.theconversation.com/files/35477/original/fm992zqd-1384749394.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=522&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/35477/original/fm992zqd-1384749394.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=522&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">When the sphincter is weak, stomach acid is forced upwards.</span>
<span class="attribution"><span class="source">Image from shutterstock.com</span></span>
</figcaption>
</figure>
<p>When the sphincter is weak or there is increased pressure within the stomach, acid can flow backwards into the oesophagus. This is often brought on by spicy or acidic food or drink, alcohol and overeating. </p>
<p>The stomach acid irritates the oesophagus, which is lined with very sensitive tissue, densely packed with sensory nerve endings.</p>
<p>In healthy people, these sensory nerves send signals to the brain alerting us to potential harm, provoking automatic reflexes such as coughing and contractions of the oesophagus. This will clear the acid or increase saliva production to neutralise the acid and protect the oesophagus. </p>
<p>There are also specialised sensory nerves that relay information via spinal cord pathways to parts of the brain that control our conscious awareness of pain. Activation of these specialised nerves triggers a pain response and, in the case of gastric reflux, drives us to reach for the Mylanta.</p>
<h2>Complications</h2>
<p>In people with a weak sphincter or an underlying illness such as a hernia or increased stomach acidity, prolonged and repetitive acid backflow may damage the oesphageal lumen lining. </p>
<p>As a result, the sensory nerves also become damaged, undergoing changes that make them abnormally sensitive and magnifying the pain signals sent to the brain. This hypersensitivity is usually temporary, but in some cases it can be permanent. </p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/35497/original/tb7vbywp-1384758013.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/35497/original/tb7vbywp-1384758013.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=471&fit=crop&dpr=1 600w, https://images.theconversation.com/files/35497/original/tb7vbywp-1384758013.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=471&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/35497/original/tb7vbywp-1384758013.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=471&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/35497/original/tb7vbywp-1384758013.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=592&fit=crop&dpr=1 754w, https://images.theconversation.com/files/35497/original/tb7vbywp-1384758013.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=592&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/35497/original/tb7vbywp-1384758013.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=592&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">To reduce your risk of an episode, avoid trigger foods, especially before bed.</span>
<span class="attribution"><span class="source">Image from shutterstock.com</span></span>
</figcaption>
</figure>
<p>If permanent, the sensitivity can trigger changes within the spinal cord “pain” pathways, making them abnormally responsive to the input they receive. If these spinal cord pathways are altered, the gastric reflux pain may become chronic and the patient may feel pain in response to normally painless stimuli or even in the absence of acid reflux. </p>
<p>The transfer of sensitivity from sensory nerves to spinal cord pathways is also <a href="http://www.thelancet.com/journals/lancet/issue/vol356no9236/PIIS0140-6736(00)X0208-5">thought to underlie</a> some of the more confusing long-term pain symptoms of gastric reflux such as non-cardiac chest pain.</p>
<h2>Treatment</h2>
<p>Over-the-counter antacids provide immediate, short-term relief. They work by neutralising stomach acidity or forming a protective layer on top of the stomach contents – or on the inner lining of the oesophagus.</p>
<p>The prescribed therapies for chronic gastric reflux sufferers are primarily aimed at reducing stomach acidity in order to prevent ongoing damage to the oesophageal lining. This allows damaged tissue to heal, and ensures that nerve endings don’t become sensitised. <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1635221/">Proton pump inhibitors</a>, a class of drugs that suppress acid, often alleviate symptoms within eight weeks. </p>
<p>But some people do not respond well to such therapy or the effects wear off over time. This may occur if the damage to the sensory nerves has been severe enough to cause remodelling of the spinal cord pathways.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/35482/original/t67bnpsq-1384749973.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/35482/original/t67bnpsq-1384749973.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/35482/original/t67bnpsq-1384749973.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/35482/original/t67bnpsq-1384749973.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/35482/original/t67bnpsq-1384749973.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/35482/original/t67bnpsq-1384749973.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/35482/original/t67bnpsq-1384749973.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Antacids provide immediate, short-term relief by naturalising stomach acidity.</span>
<span class="attribution"><span class="source">dianaschnuth</span></span>
</figcaption>
</figure>
<p>As such, it’s important to identify and understand the workings of these specialised sensory nerves and the spinal cord pathways that relay pain information. This is what my colleagues and I sought to do in a <a href="http://www.ncbi.nlm.nih.gov/pubmed/23848546">recently published study</a> examining the neurological activity of mice with acute acid reflux. We were able to identify the sensory neurons activated by oesophageal acid, and the spinal cord “pain” pathways they relay information into. </p>
<p>Such information will allow us to identify changes within this pathway due to chronic acid exposure. This is key to our understanding of what causes gastric reflux pain, and may explain why current therapies are not effective in some people. It will also allow us to improve therapies, with alternate treatments <a href="http://www.ncbi.nlm.nih.gov/pubmed/23998982">being developed</a> that are aimed at correcting the sensitivity of damaged sensory nerves.</p>
<p>If you’re concerned about gastric reflux, talk to your general practitioner about possible treatments. In the meantime, there are some <a href="http://www.mayoclinic.com/health/gerd/DS00967/DSECTION=lifestyle-and-home-remedies">steps you can take</a> to reduce reduce your risk of an episode, such as eating smaller meals, watching your weight and avoiding trigger foods, especially before bed.</p><img src="https://counter.theconversation.com/content/18791/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrea Harrington receives funding from the Australian Research Council</span></em></p>If you’re prone to gastric reflux, you’ll probably be watching closely what you eat and drink during the pre-Christmas party season. You’re certainly not alone; modern, heavy eating habits and a rise in…Andrea Harrington, ARC DECRA Research Fellow, University of AdelaideLicensed as Creative Commons – attribution, no derivatives.