1. Home>
2. Specialties>
3. Gastroenterology>
4. Summary and Comment

GERD and Sleep Disturbance

Nonacid reflux events might explain refractory sleep disturbance during PPI therapy.

In some patients with sleep disturbance, gastroesophageal reflux disease (GERD) plays a pathogenic role. Nocturnal acid reflux can cause awakenings, due to cognitive recognition of heartburn or regurgitation symptoms. In addition, gastric refluxate into the esophagus can induce sensory arousal to stimulate secondary clearance without cognitive awakening, and this sensory effect might disrupt sleep by interfering with sleep-stage progression. Proton-pump inhibitors (PPIs) benefit patients with GERD-associated sleep complaints, but the response rate for preventing sleep disturbances is considerably lower than the response rate for alleviating traditional GERD symptoms; this distinction suggests that nonacid (bile) reflux events contribute to sleep disturbance during PPI therapy.

In this industry-supported, prospective, double-blind, controlled, crossover study, 15 patients with GERD were randomized to receive daily esomeprazole (40 mg in 2 doses) or placebo for 1 week. After therapy was completed, impedance pH testing and polysomnography were performed on all participants in a sleep laboratory. Before recumbence in the lab, patients received meals to provoke reflux events and enhance assessment of treatment effect. Patients then crossed over to the other treatment arm and underwent the same tests 1 week later.

Overall, acid reflux events were significantly more common with placebo than with PPI therapy. Nonacid reflux events were somewhat, but not significantly, more common with PPI therapy than with placebo. Sleep-related acid reflux events were more common with placebo than with PPI therapy (P<0.01). Sleep-related nonacid reflux events were somewhat more common with PPI therapy than with placebo (P=0.07). No significant difference was found in the percentage of sleep arousals associated with acid and nonacid reflux events (68% and 89%). Clearance responses and suppression of proximal migration of refluxate were seen equally often during acid and nonacid reflux events. No significant differences by treatment were reported for objective sleep measures (total time, sleep latency onset, or sleep efficiency).

Comment: Researchers have never reported before that arousals from sleep were equally likely to occur during acid reflux and nonacid reflux events. These investigators did not supply a justification for their relatively small sample size; the lack of significant difference for improvement in the sleep parameters between active therapy and placebo might reflect a type II error for this small sample. Because these patients all consumed provocative meals before recumbence, these findings might not reflect standard patient practice. However, nonacid reflux could explain GERD-related sleep disturbances that persist despite PPI therapy. Further appropriately powered studies will be needed to better define specific treatment effects.

— David A. Johnson, MD

Published in Journal Watch Gastroenterology May 18, 2007

Citation(s):

Orr WC et al. Acidic and non-acidic reflux during sleep under conditions of powerful acid suppression. Chest 2007 Feb; 131:460-5.

• Medline abstract (Free)

2011 Top Stories