The Special Risks of Nighttime Heartburn

Nighttime heartburn is painful. It disrupts your sleep and it can lead to serious medical problems.

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For the past seven years, Dave White of Easthampton, Mass., has slept with his head and chest uncomfortably propped up on a pile of pillows.

"It's the most difficult part of living with this condition," White says. "There are times when I've almost wept from the frustration of having to sleep [this way]." But if he doesn't, he risks a flare-up that sometimes "feels like a lit match being pressed to the top of my stomach."

That condition is chronic heartburn, also known as GERD -- gastroesophageal reflux disease. For most people, heartburn is an occasional nuisance. It descends after an all-you-can-eat buffet or an office party. But if you have heartburn regularly, it's likely a sign of GERD, a relentless condition in which stomach acids back up into the esophagus. According to the American Gastroenterological Association, 25 million people have heartburn every day.

For many of them -- at least 50% according to some research -- nighttime heartburn is a special problem. Since lying flat can aggravate the symptoms, trying to sleep can be painful and difficult. There can also be more serious long-term consequences. Studies show that nighttime heartburn increases the risk of developing other serious conditions, including cancer of the esophagus.

The good news is that there's a lot you can do to relieve the pain and discomfort. "If you are experiencing nighttime heartburn, you should know that there are good treatments," says Stuart Spechler, MD, spokesman for the American Gastroenterological Association and chief of the division of gastroenterology at the Dallas VA Medical Center. "There's no reason anyone should be suffering with this."

Why Is Nighttime Heartburn More Dangerous?

Day or night, chronic reflux can gradually damage the esophagus. It may lead to inflammation and scar tissue that narrows the esophagus. In some people, chronic heartburn can lead to Barrett's esophagus, changes in the cells that increase the risk of esophageal cancer.

But nighttime heartburn tends to leave acid in the esophagus longer, and therefore may cause more damage than daytime heartburn.

"A good part of the explanation is gravity," says Lawrence J. Cheskin, MD, co-author of Healing Heartburn and associate professor of medicine at the Johns Hopkins School of Medicine in Baltimore, Md. During the day, acids from the stomach may briefly force their way into your esophagus. But gravity quickly pulls them back down to the stomach.

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When you're lying down, gravity isn't pulling in the right direction. Instead, the stomach contents are pressing on the sphincter muscle that connects the esophagus to the stomach. In people with GERD - which means nearly everyone with chronic heartburn - the sphincter is faulty. It doesn't fully close. So acids can reflux back up into the esophagus. And because you're lying down, once acids get into the esophagus, they can sit there for much longer than during the day. That can increase the damage.

Gravity isn't the only factor. When you're awake, you naturally swallow whenever acid begins to reflux. This pushes the acid back down into the stomach. Saliva also contains bicarbonate, which can neutralize stomach acid. But when you're asleep, the swallowing impulse is suppressed, Spechler says.

The Link Between Nighttime Heartburn and Insomnia

The effects of nighttime heartburn aren't confined to esophagus. It can also result in chronic insomnia. Nighttime heartburn can wake you up and keep you up.

"The symptoms definitely aggravate insomnia," says Dave White, who has suffered from nighttime heartburn for years. "I'll wake up with cutting heartburn pain and then have to wait for the effects of [medicine] to kick in, which can take an hour or so. When that happens, I'll just get out of bed, since I know I'll be up anyway."

One study showed just how common nighttime heartburn can be. Researchers questioned nearly 15,300 average people and found that a whopping 25% reported having nighttime heartburn. The results were published in the journal CHEST.

Another survey of 1,900 people with GERD in the U.S. and Europe found that about half had trouble sleeping at night. In these people, GERD symptoms caused a 22% impairment of leisure activities and a 15% impairment of their ability to work. The findings were presented during the 2005 Digestive Disease Week, an international conference for gastroenterologists. So the pain -- and consequences -- of nighttime heartburn go well beyond that burning in your chest.

Controlling Nighttime Heartburn

Fortunately, there are a lot of different treatments for nighttime heartburn. They can reduce your symptoms and your discomfort. They also lower the risk of developing serious complications.

"Lifestyle changes are very important," Cheskin tells WebMD. "In so many cases, we don't need to go to prescribed medications or more aggressive treatments." Many people can find relief by:

  • Avoiding foods that can lead to heartburn, such as alcohol, chocolate, peppermint, coffee, carbonated drinks, citrus fruits and juices, tomatoes, pepper, vinegar, catsup and mustard, and spicy or fatty foods
  • Not eating anything for two to three hours before bedtime
  • Chewing gum in the evening to boost saliva
  • Putting blocks under the top of the mattress to elevate the head 4 to 6 inches

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OTC Medicines for Heartburn

If changes to your lifestyle don't ease your nighttime heartburn, over-the-counter medications may do the trick, Cheskin says. The tried and true treatments -- the ones your mom always gave you -- are antacids, which neutralize the acid in the stomach. These include liquids like Maalox or Mylanta, and solid tablets like Rolaids or Tums. "They can be very effective," Cheskin says, "but the problem is that you have to take them more frequently, since they only last a couple of hours."

But Spechler is skeptical. In cases of GERD that are bad enough to require them, he thinks that medicine is usually more effective and easier to live with. "Frankly," Spechler says, "unless the condition is especially severe, or there's some very compelling reason why a person shouldn't take medicine, I don't see any reason to torture patients with very tight dietary restrictions or elevating the head of the bed."

Another class of over-the-counter medicines is H2 receptor antagonists, which reduce the production of acid by the stomach. Some examples are Pepcid AC, Tagamet HB, Zantac 75, and Axid AR.

Studies show that over-the-counter medications can help with symptoms in 60% to 70% of people with chronic heartburn or GERD.

Treating Severe Heartburn and GERD

The newest -- and most effective -- class of heartburn drugs are the proton pump inhibitors. These work by blocking the effects of an enzyme that produces acid in the stomach. So far, only Prilosec OTC is available over-the-counter. Other proton pump inhibitors, such as Aciphex, Nexium, Prevacid, and Protonix, are available with a prescription from your doctor.

A lot of people find that one prescription medication on its own may not be enough. For severe GERD, Spechler says that you may need not only one to two daily doses of a proton pump inhibitor, but also a bedtime dose of an H2 receptor antagonist. You may need over-the-counter antacids, too. In some cases, your doctor may recommend surgery to correct the problem that's causing your symptoms. But surgery isn't always a complete solution. Some people still wind up needing medication afterwards. Be sure you're under a doctor's care if you take heartburn drugs regularly. They can slightly increase the risk of pneumonia.

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The key is to get treatment. If you have frequent nighttime heartburn -- and lifestyle changes aren't helping -- see your doctor.

"In recent years, we've become more and more aware of GERD as a risk for much more serious conditions, even cancer," says Cheskin. "It's not just heartburn. So you shouldn't be complacent about it until you have it checked out."

As for White, he says that treatment with a proton pump inhibitor has made a big difference. His symptoms have improved dramatically over the last few years. Nonetheless, his case is severe and his says his doctor thinks he may need surgery in the future.

WebMD Feature Reviewed by Brunilda Nazario, MD on April 13, 2009

Sources

SOURCES: Lawrence J. Cheskin, MD, FACP, co-author of Healing Heartburn; director and founder, Johns Hopkins Weight Management Center; associate professor, international health and human nutrition; and associate professor of medicine, Johns Hopkins School of Medicine. Stuart Spechler, MD, spokesman, American Gastroenterological Association; and chief, division of gastroenterology, Dallas VA Medical Center; professor of medicine, University of Texas Southwestern Medical Center at Dallas. David White, Easthampton, Mass. The American Gastroenterological Association web site. The National Heartburn Alliance web site. The National Institute of Diabetes and Digestive and Kidney Disorders web site. Fass, R. CHEST, 2005; vol 127: pp 1658-1666. News Release, University of California, Los Angeles (UCLA), May 16, 2005.

© 2005 WebMD, Inc. All rights reserved.

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