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In this evolving landscape of healthcare, where the focus increasingly shifts towards personalized and preventive care, a critical area requiring our attention is the management of gastroesophageal reflux disease (GERD) and the judicious use of proton pump inhibitors (PPIs). As I complete my final semester of my post-MSN to DNP doctorate program, I've been wrapping up a quality improvement project aimed at addressing the challenges of deprescribing PPIs in a gastroenterology clinic setting. This experience has validated not only the complexities of PPI deprescribing but also the pressing need to educate both healthcare providers and patients about the risks associated with long-term PPI use and the holistic alternatives that are available.
The Double-Edged Sword of PPI Usage
PPIs are among the most prescribed medications worldwide, lauded for their efficacy in managing GERD symptoms, as well as healing ulcers and esophageal damage. However, their use is not without risk. Long-term PPI use has been associated with a myriad of adverse health effects, including kidney and liver diseases, osteoporosis, dementia, cardiovascular issues, an increased risk of infections, gastric neoplasms, and impaired nutrient absorption (Abbas et al., 2019; Aubert et al., 2023; Edinoff et al., 2023; Fossmark et al., 2019; Gao et al., 2022; Gomm et al., 2016; Jaynes & Kumar, 2018; Katz et al., 2022; Lespessailles & Toumi, 2022; Maideen, 2023; Newberry & Lynch, 2019; Strand et al., 2017; Thong et al., 2019; Tian et al., 2023; Torres-Bondia et al., 2022; Xun et al., 2022; Yibirin et al., 2021; Yozgat et al., 2021). Despite a growing body of evidence confirming these mounting concerns for long-term PPI use and placement on the BEERS list of medications to use with caution in older adults, it continues to be one of the most frequently prescribed medications in the world, and approximately one in four Medicare Part D recipients regularly take a prescribed PPI (Toth et al, 2022). In response to this, the American Gastroenterological Association (AGA) introduced formal deprescribing guidelines in 2022 to emphasize the necessity to reassess PPI usage. This current quality improvement project focuses on implementing the AGA deprescribing guidelines systematically in a busy gastroenterology clinic.
Why the Long-Term Commitment to PPIs?
Patients often commence PPI therapy to control GERD symptoms, enjoying the immediate relief it provides from epigastric pain. However, this short-term solution can quickly transition into a long-term dependency, partly due to the rebound acid hypersecretion experienced when attempting to discontinue the medication. This phenomenon, coupled with a lack of awareness about alternative management strategies and risks of long term use, leads to prolonged PPI use, often beyond what is medically justified.
A Path to Holistic GERD Management
In this particular clinic's journey to empower healthcare providers and patients to embrace deprescribing, I've highlighted for them what we know so well in functional medicine- the immense value of integrating holistic practices into GERD management.
But, to better understand how to address GERD in a holistic manner, we must first acknowledge why GERD is the most prevalent gastrointestinal disorder in the United States. GERD isn't about stomach acid that is too acidic, but that is how it is treated in the allopathic approach. In reality, it is important for nurses and their patients to acknowledge that GERD is about stomach acid in the wrong place. It develops when stomach acid flows back into the esophagus through the lower esophageal sphincter (LES). This backwash (acid reflux) can irritate the lining of the esophagus, leading to GERD. Several common, modern lifestyle factors significantly contribute to its development and explain why GERD has increased in prevalence so rapidly (AKA we can't simply blame GERD on our genetics or luck). Here are a few of the most common contributors:
Meal Timing:Â Eating late at night or too close to lying down for sleep can increase the likelihood of acid reflux.
Trigger Foods: Certain foods and beverages, such as spicy foods, citrus fruits, chocolate, caffeine, and alcohol, can also trigger symptoms.
Stress:Â Chronic stress doesn't just strain your mental health; it can also exacerbate GERD symptoms. Stress may lead to increased acid production in the stomach and can also impact the closure of the lower esophageal sphincter, making it easier for acid to escape into the esophagus. As we know well in functional medicine, stress can come in many forms including lack of quality sleep.
Eating Hygiene:Â On average, we chew about five times for each bite, but in reality we should be chewing about 30 times per bit. Our hurried lifestyles tend to make us eat meals much faster than we should. Our mouth is responsible for much of the heavy lifting of mechanical food digestion, but when we don't chew enough, we are relying on our stomachs to do too much of the work. Plus, it takes twenty minutes for our brains to receive the signal we are full, so when we eat quickly, we are often consuming much more than we should because we don't slow down enough to listen to our body's natural cues regarding portion sizes.
Portion Sizes Including Large Beverages with Meals:Â Eating large portions at one time can put extra pressure on the stomach and the lower esophageal sphincter leading to reflux. Smaller, more frequent meals can help mitigate this risk, reducing the likelihood of acid making its way back up the esophagus.
Understanding the impact personal choices play in GERD development and management is crucial for patients, as managing lifestyle, reducing stress, and adjusting portion sizes can be powerful steps in alleviating GERD symptoms and improving quality of life.
Diet and Lifestyle Modifications:Â The cornerstone of GERD management lies in dietary and lifestyle changes. Encouraging patients to maintain a healthy weight, avoid trigger foods (such as spicy, fatty, or acidic foods), chew foods thoroughly, eat more slowly, and adopt a balanced diet rich in whole foods can significantly reduce GERD symptoms.
Stress Management:Â Stress is a known exacerbator of GERD. Techniques such as mindfulness, yoga, and breathing exercises can help manage stress levels, thereby mitigating GERD symptoms.
Addressing Portion Sizes and Beverage Consumption: One of the most impactful measures for addressing GERD is simply having patients pay attention to the amount of food they consume at one time as well as the amount of beverages they have with their meals. When we remember the actual size of our stomach, it's easy to see that a big gulp-sized beverage with a large meal is going to challenge the limits of our stomach's ability to keep contents where they belong. It's amazing how much fewer symptoms my patients experience when they simply reduce the amount of beverages they have with meals. I find educating patients on the lower esophageal sphincter being like a pressure relief valve is a great analogy for getting buy-in to reduce portion sizes of meals and total beverage consumption during meals. It is much better to consume beverages between meals and focus on healthy beverage choices like water, carbonated water, and herbal teas.
Patient Education:Â Empowering patients with knowledge about the potential risks of long-term PPI use and the benefits of holistic management strategies is key. Providing resources and support can facilitate a smoother transition from PPIs. In my current project, we are focused on using the deprescribing guidelines to provide patient education and a taper plan that includes a plan for breakthrough symptoms. This comprehensive approach to patient education and patient involvement in the plan of care are cornerstones of any holistic practice.
The journey to reducing the reliance on PPIs and incorporating holistic GERD management practices is multifaceted, requiring a concerted effort from both healthcare providers and patients. By prioritizing education, evidence-based alternatives, and personalized care, we can navigate toward a future where the management of GERD aligns with the broader principles of health and well-being that guide our practice as nurses and nurse practitioners. I can't wait to share the results of the quality improvement project in the coming months and GRADUATE!
Educating and empowering your patients is fully within the scope of RNs and NPs, and this important nursing skill can play a major role in improving our patients' health outcomes- especially on topics like risks of long-term medication use and holistic approaches to healing. For nursing professionals eager to deepen their understanding of these types of intricate health connections that can enhance their clinical practice, I teach the Functional Medicine for Nursesâ„¢ course through the Integrative Nurse Coach Academy in partnership with the Institute for Functional Medicine. This course is designed to blend the functional medicine approach with the nursing perspective. By enrolling, you'll gain comprehensive insights into functional medicine principles, including in-depth explorations of topics like this, and how to apply this knowledge in nursing practice. This training is not just about acquiring information; it's about empowering you to transform patient care and become a leader in the field of holistic nursing and functional medicine. If you're passionate about advancing your career and enhancing your ability to heal, I invite you to join us and take the next step in your professional journey. Learn more here.