Reflux and Scleroderma: Why You Want to Avoid PPIs + Effective Drugless Solutions

Heartburn, GERD, reflux—whatever name you use it is always unpleasant and can sometimes be painful and even lead to more serious conditions. It is an incredibly common symptom in the general population and even more common in people diagnosed with scleroderma (CREST and systemic sclerosis). This article contains pearls on how anyone can rid themself of reflux but will in particular focus on those with scleroderma—one of my favorite populations of people to work with since Naturopathic medicine offers so many solutions for this often devastating condition.

In this article, we’ll cover:

What reflux is
Why natural and common-sense solutions for resolving GERD in the general population will often work for those with the scleroderma as well
Why avoiding conventional medications for GERD, over the counter and prescription, whenever possible is so important
Why avoiding the drugs might be especially important if you have scleroderma or other autoimmune conditions
Simple and key changes you can make to heal reflux without drugs
Tips on next steps you can take if these changes are not sufficient

What is GERD/reflux/heartburn?

GERD stands for gastroesophageal reflux disease. It is sometimes shortened to reflux and it is the official name for the sensations people usually call heartburn. GERD occurs when the contents of the stomach travel up into the throat and cause a burning sensation there. A more subtle symptom of reflux can be a sensation of pressure on the chest. It is generally thought to be from too much stomach acid but there can actually be a number of more common causes. These include a weak esophageal sphincter, slow stomach emptying, bloating or slow motility further down in the gut, food sensitivities, emotions and more.

If I have scleroderma, isn’t the reflux simply caused by sclerosing of my esophagus?

When a person with scleroderma experiences reflux, the assumption is often that this is occurring because of scleroderma, either from sclerosing in the esophagus itself or from sclerosing further down in the digestive tract causing decreased motility and delayed emptying of the stomach. This can be true, but those with scleroderma may also experience heartburn for many of the same reasons anyone without scleroderma might.

Years ago, I gave a talk to a local Scleroderma support group on GERD. About an hour into the talk, after I had covered many factors that can contribute to reflux, a young woman in the group raised her hand to inform me that in people with scleroderma, reflux is caused by the sclerosing of the esophagus. Period. What she didn’t say, but her tone and posture implied, was “Lady, you don’t know what you’re talking about and none of this is relevant to us. We have scleroderma and that is why we have reflux.” This happens in chronic disease: people and doctors sometimes forget that the disease is happening in a person where any number of factors could be causing their symptom besides the disease process itself.

GERD may or may not be directly caused by the disease process of scleroderma, so it is important that all the normal, pedestrian reasons for reflux (which are usually relatively simple to address) be considered before just saying it is an inevitable symptom of the disease that needs to be lived with or treated with pharmaceutical medications. Afterall, an estimated 20% of American’s have reflux and most of them do not have scleroderma as an underlying cause. You could easily have scleroderma but also have reflux as an independent issue. (Okay, truthfully, as a naturopathic doctor, I never really see symptoms in the same person as totally independent of each other, but we can sometimes at least say that one is not directly caused by the disease process of the other.) Even if you do have sclerosing in your esophagus, this does not mean that your body won’t respond to many of the same basic approaches that other people’s bodies do. Many of the approaches I use to help patients stop reflux are aimed at supporting your body’s normal physiology (functioning). This is a way to increase health in the body. Anytime we do this, we see fewer symptoms of disease. So, even if you are convinced that the reflux you are experiencing is directly from sclerosing, don’t underestimate the seemingly simple advice and next steps we’ll cover here.

Why not just use PPIs or antacids to control symptoms of reflux?

The conventional treatment for GERD is usually over the counter or prescription medications and, sometimes, a few basic lifestyle modifications. While these medications have their time and place, they aren’t great long-term solutions for ANYONE and may have potential long-term effects that could be worse for those with autoimmunity and scleroderma specifically.

To understand why the drugs used to treat reflux aren’t great for your overall or long-term health, you need to appreciate your stomach and all the amazing functions that take place there. The stomach isn’t just a place for food to sit on the way to intestines. Many important functions take place there. The steps of digestion that take place in your stomach are crucial for accessing minerals, B12 and protein from the food you’re eating. Because of this, without a properly functioning stomach, you are at risk for nutrient deficiencies. A stomach that secretes all the right digestive juices, including stomach acid, in the right amounts is also crucial for the health and function of your entire digestive tract. These secretions help signal the rest of the digestive tract to function properly. This includes motility of the digestive tract. You gut needs to have regular downward movements to keep food moving through it and all its bacterial inhabitants in the right place. If this isn’t happening, you’ll likely end up with constipation and possibly with small intestinal bacterial overgrowth (more on this soon), the recirculation of toxins into your body and more.

The drugs used to treat reflux are aimed primarily at neutralizing acid or reducing production of acid in the stomach. Stomach acid is necessary for a properly functioning stomach. If you eliminate stomach acid long term, you’ll end up with many side effects. Some of these side effects could theoretically worsen autoimmunity and many are likely to create additional disease, conditions and symptoms.

Here are the most common drugs used to treat GERD:

Proton Pump Inhibitors (PPIs): omeprazole/Prilosec, lansoprazole/Prevacid, rabeprazole/Aciphex, esomeprazole/Nexium
Antacids: Tums, Maalox, Mylanta, Rolaids
H-2-receptor blockers: cimetidine (Tagamet), famotidine (Pecid AC, Pepcid Oral, Zantac 360) and ranitidine (Zantac, no longer on the US market)

These all change the acid level in your stomach through varying mechanisms, but the results are similar because all three categories of drugs can lead to:

Vitamin and mineral deficiencies, especially B12, vitamin C, calcium, and magnesium
Decreased gut motility
Changes in the gut microbiome

PPIs have been associated with increased risks for:

Osteoporosis and fractures (1)
Chronic and acute renal (kidney) disease (1)
Community acquired pneumonia (1)
Clostridium difficile infection (bacterial infection in the gut) (1)
An alteration in the gut microbiome (2, 3)
SIBO (small intestinal bacterial overgrowth) (2)
More severe COVID infections with a higher likelihood of developing a secondary infection (4)
Developing autoimmunity- one study found a 300% increased risk with PPI use (5)

H2 blockers have a weaker effect on acid suppression than PPIs and are generally considered a safer choice. However, there is still evidence that they alter the gut microbiome (6), even after just a week of use (7). Cimetidine may also cause disruption to the gut barrier (8), aka Leaky Gut.

A major problem with all pharmaceutical treatments for GERD is that many people use them for much longer than their intended use and this means a higher likely hood of unfavorably altering the microbiome, altering gut function, and creating nutrient deficiencies. Acid suppressants are usually only meant to be taken for two weeks. It is not uncommon for me to meet new patients who have been on these medications for years. I am not totally surprised by this. The medications don’t treat any underlying causes of GERD, they just cover up the symptom. This means if a patient stops the medication after two weeks, the GERD is very likely to come back….and sometimes with a vicious rebound.

Could long-term reliance on these drugs be worse for those with scleroderma? And why might reflux drugs contribute to the development of autoimmunity?

Since approximately 80% of your immune system is in the lining of your gut, it is easy to imagine how a drug that changes one of the crucial first steps in digestion could have profound impacts on the health and balance of your immune system. The studies cited above provide much of the evidence for this: with PPIs and H2 blockers we see an increase in infections, worse infections and more autoimmunity. These are all signs that the immune system is compromised and imbalanced.

What might some of the mechanisms for increased autoimmunity be? PPIs may increase leaky gut. Leaky gut, the colloquial term for intestinal permeability, is often considered by naturopathic doctors and functional medicine doctors to be an important factor in the development and perpetuation of autoimmunity. Mice studies have suggested that PPIs can enhance leaky gut (6). In naturopathic medicine, improperly digested food, as you are likely to see with reduced stomach acid, is considered a risk factor for the development of leaky gut. A disrupted microbiome can alter the gut lining and permeability as well. You can see why PPI use may be associated with such a dramatic increase in risk for autoimmune diseases. Healing leaky gut is a crucial part of healing from autoimmunity or at least slowing down progression from the disease. It is very hard to heal leaky gut while on pharmaceutical treatment for reflux.

Although none of the potential side effects of the drugs are great for anyone, I have special concern for those with scleroderma. People with scleroderma are already at an increased risk for SIBO if the sclerosing process impacts any part of gut motility, which it often does. Compounding this with a PPI isn’t a great scenario. For those of you unfamiliar with SIBO, or Small Intestinal Bacterial Overgrowth, it is a condition involving an altered gut microbiome and too many bacteria in the small intestines. SIBO can cause symptoms including constipation, diarrhea, and severe bloating. It often decreases absorption of nutrients. If a PPI contributes to SIBO and decreases nutrients both through its direct action on the stomach and the impact of SIBO on the ability to absorb nutrients in the small intestine, you could end up very depleted of the nutrients you need to heal your immune system and feel your best. I suspect that the disruption to the gut may worsen and continue to stoke the flames of autoimmunity. If a PPI can increase your risk of developing an autoimmune disease so dramatically, it is logical that it could also prevent you from going into remission or even speed up the course of the disease. I did not find any studies to back up either of these ideas but they make good common sense as possible outcomes and there are not studies refuting the idea either. I have seen firsthand how a healthy gut is key to healing form autoimmunity.

What can you do instead to heal reflux instead of taking pharmaceuticals?

Many of the non-pharma solutions for GERD are so simple, it is almost ridiculous. I find that a significant number of patients see reflux symptoms resolve when they do an elimination diet and implement simple food “hygiene” habits.

Conventional recommendations for dietary changes to control GERD usually focus on eliminating or reducing the following foods: chocolate, alcohol, caffeine, spicey foods, mint, carbonated beverages, citrus fruits, tomatoes, and fried foods. In my experience, many other types of food sensitivities can trigger GERD, including sensitivities to gluten, dairy, and corn. Even highly processed foods or too many refined carbohydrates can trigger GERD. My go to recommendation for GERD, especially in the setting of an autoimmune condition, is often to start a patient off on an Auto-Immune/Anti-Inflammatory Paleo diet. This can help eliminate GERD related to food sensitivity triggers but may also be helpful in eliminating GERD that is directly related to the autoimmune process itself. You might be skeptical that a dietary change could possibly reverse symptoms of an autoimmune process. In my experience, starting a patient on an AIP diet is one of the fastest ways to stop irritating their immune system and fueling autoimmunity. If you haven’t read it yet, be sure to read my post on scleroderma and AIP. The blog illustrates just how quickly adopting an AIP diet can change the course of a disease. The scleroderma patient I wrote about not only had symptoms of GERD reduce drastically within days of starting the diet, within weeks she had marked improvement in her skin quality and flexibility in her hands. You might argue that an AIP diet simply removed a food trigger for GERD, but the changes in her skin and hands suggest that the whole scleroderma process became less active as well. My conclusion? An AIP diet may have reduced active autoimmunity in her GI tract, resulting in less reflux. Simply eliminating the common GERD triggers is not likely to have had this same impact.

Although I’ve found AIP to be one of the most effective elimination diets in identifying foods related to reflux, I will use other therapeutic diets based on the symptoms of the individual. Low FODMAPs is one of these. Spoiler alert- if you respond well to a Low FODMAPs diet, you more likely than not have SIBO.

Curing reflux isn’t just about what you eat, how you eat can have a big impact on symptoms as well. This is true for anyone with reflux but especially true for those with autoimmune diseases, including scleroderma. Why is this? It comes back to the incredible impact the health of your digestive tract has on the balance of your immune system. How you eat impacts not just your stomach acid but also the health of your digestive tract all the way down. With nearly 80% of your immune system residing in your gut, you want a healthy digestive tract through and through to slow the progression of autoimmunity or even stop it in its tracks. If you are curious to learn more about this, check out my blog on Leaky Gut. Here are a few basic tips to start implementing but be sure to check out the two blogs linked below for more details:

Make sure that you chew incredibly well. I often ask people to chew each bite 31 times. I invite them to try this for at least a few meals to see how broken down their food should be before swallowing.
Eat in a non-stressful environment. Don’t eat while working, driving, or having tense conversations. Stress puts us in a fight or flight state, and this signals the body to shut down digestion.
Take ¼- 1 tsp organic apply cider vinegar in a little water 0-30 minutes before meals to help regulate your digestive juices, including stomach acid. Taking vinegar might seem counter intuitive to us because it tastes acidic and seems like it might compound the issue. However, it is actually much less acidic than stomach acid and you should remember the earlier list of reasons we have GERD other than high stomach acid. ACV helps address many of these other reasons.

There are more details on the hows and whys of good eating habits in my very first two blogs here and here.

What if these simple techniques aren’t enough?

There are many next steps to explore, so please don’t feel like you’ll be on a PPI or have reflux forever if an elimination diet and changing your eating habits doesn’t do the trick. Here are some of the other avenues I have exploded with patients:

Addressing stress and other mental/emotional factors that may be impacting digestion. One way to dig into a mental emotional cause might be to ask “What is it that I am having trouble swallowing in my life?” Other tools we use for uncovering mental/emotional connections include Emotion Code, Vis Dialogue and Unda Numbers.
Visceral manipulation—I’ve found that if the stomach is riding just a little too high in the digestive tract, GERD is much more likely. This is referred to as a hiatal hernia. If it is severe, it may need to be surgically corrected, but I’ve found that most of my patients benefit from a simple 3 minute in-office adjustment that encourages the stomach back into place. Many naturopathic doctors can do this for you. There are also PTs that specialize in visceral manipulation and have more advanced techniques. I have sent some tough GI patients to visceral PTs for support with great outcomes.
Testing for or presumptively treating a disrupted microbiome. Testing can be done through stools, breath, or urine samples. Unhappy bacteria, parasites or fungal overgrowth can all contribute to conditions that result in GERD.
Constitutional Hydrotherapies are an amazing therapy and a naturopathic specialty! The treatment consists of hot and cold applications to the torso and back along with gentle stimulation to the spinal nerves (which innervate your digestive tract) using a sine wave machine. It is relaxing but, more importantly, supportive of your immune system, detox pathways, and digestion. Although the names sound similar, it is totally different from colonic hydrotherapy.
Other individualized digestive support with herbs and supplements can be utilized
Continue working to balance the autoimmune process

I hope this information will be helpful for you in resolving GERD. Obviously, much of the information and many of the tips are applicable to anyone with reflux, not just those with scleroderma. If you know someone suffering from reflux or dependence on PPIs or antacids, please share this with them.

If you’d like individualized support in healing GERD, addressing scleroderma more broadly, or healing from autoimmunity please fill out our Potential New Patient Questionnaire. We are here to help!