I have acid reflux at night. What to do if pills don't work?

Question

Hello doctor,

I am 39 and have been experiencing frequent acid reflux and heartburn, especially at night. My endoscopy last month showed mild esophagitis but no ulcers. I have been on Omeprazole 20 milligrams daily for three weeks now, but symptoms persist.

I avoid coffee and spicy food and do not eat late, yet I wake up coughing or with a bitter taste. However, I have a few concerns.

Is this likely silent reflux or something else?
Should I increase the PPI (proton pump inhibitor) dose or try something else?
I have read that long-term PPI use can affect calcium and B12. Should I worry about that?

What else can I do if medication alone is not helping much?

Kindly suggest.

Answer 1

Hello,

Welcome to icliniq.com.

I understand your concern.

Given your symptoms of nighttime acid reflux, a recent endoscopy showing mild esophagitis, and ongoing discomfort despite Omeprazole 20 milligrams once daily for three weeks, you may be experiencing incomplete acid suppression or laryngopharyngeal reflux (LPR), also known as silent reflux.

LPR often causes nighttime coughing, throat irritation, and a bitter taste, even without classic heartburn. It would be reasonable to increase Omeprazole to 20 milligrams twice daily, taken 30 to 60 minutes before breakfast and dinner. Once-daily dosing may not be sufficient for some individuals.

If symptoms persist after eight weeks of twice-daily dosing, further steps could include:

Switching to a different PPI (proton pump inhibitor).
Adding an H2 blocker (like Ranitidine or Famotidine) at bedtime,
Or undergoing further evaluation.

Keep in mind, LPR can involve non-acid components like pepsin or bile, which do not respond well to PPIs alone. A 24-hour pH impedance study may be useful to confirm the nature of the reflux.

You are also right to be mindful of long-term PPI use. Studies have linked prolonged high-dose use to reduced absorption of calcium, magnesium, and vitamin B12, and possibly an increased risk of bone thinning or fractures. These risks are more significant in people taking PPIs for over a year.

If long-term use is necessary, I suggest:

Periodic monitoring of vitamin B12 and magnesium levels, and possibly bone density screening if you have risk factors for osteoporosis.
In addition to medication, lifestyle changes remain important. Elevate the head of your bed by six to eight inches (not just using extra pillows), avoid lying down within three hours of eating, and try smaller, more frequent meals.
If you are overweight, even modest weight loss can greatly improve symptoms. A low-acid or alkaline diet may also help some people with LPR.
You may also benefit from trying alginate-based antacids like Gaviscon Advance (sodium alginate, sodium bicarbonate, and calcium carbonate), which create a barrier on top of stomach contents and can help reduce nighttime reflux episodes.

I hope this information helps you.