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GERD Treatment during Fasting Ramadan

Changes in eating patterns during the holy month of fasting (Ramadan) are feared to trigger or increase the severity of gastroesophageal reflux disease. Therefore, the doctor needs to understand the treatment procedures of GERD.

GERD Treatment during Fasting Ramadan
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GERD or acid reflux disease is a digestive disorder that occurs when stomach acid frequently flows back into the esophagus. GERD is quite common, with prevalence reaching 18.1-27.8% in North America and 2.5-7.8% in East Asia.

Some studies state that fasting, or the willful refrainment from eating and drinking for a set period (from dawn to sunset), can interfere with stomach acid. This certainly can affect patients who have a history of GERD. However, several other studies state that fasting has a good effect on GERD.


The Controversy of the Effects of  Ramadan Fasting on GERD

Can Ramadan Fasting help or make  GERD?

Some researches show controversial results regarding the effect of fasting on GERD. Some studies state that fasting can increase the incidence of GERD, but other studies report that fasting can reduce GERD complaints.

A systematic review by Seifi et al. regarding the effect of Ramadan fasting on gastrointestinal disorders, there is an increase in gastric acid and pepsin secretion during Ramadan fasting.

Ramadan fasting can be beneficial for healthy individuals. However, in patients with gastrointestinal disorders, Ramadan fasting can increase complaints, such as dyspepsia, and the risk of complications from digestive disorders. This study suggests that patients who have gastrointestinal complaints, including GERD, should receive medication before starting fasting. 

Rahimi et al. conducted a longitudinal study examining 69 samples. Of the 69 samples, 33 subjects fasted, and 36 did not fast. There were no significant differences in GERD complaints between groups undergoing Ramadan fasting and those not fasting. With ethical considerations, the two groups were given medicines, namely antisecretory drugs (histamine H2 receptor antagonists and PPI). Therefore, it can be concluded that Ramadan fasting does not affect GERD symptoms in patients receiving antisecretory drugs. This study has limited small sample sizes and a lack of data on drug types consumed by patients.

GERD Treatment

Appropriate management of GERD can certainly help patients who want to practice fasting during the month of Ramadan. Based on the American College of Gastroenterology (ACG), GERD management includes non-pharmacology, pharmacology, endoscopy, and surgical management.

GERD Treatment targets are: 

  • to relieve complaints, 
  • cure esophageal lesions, 
  • prevent recurrence of disease, 
  • improve life quality, 
  • prevent complications such as Barrage of the esophagus, erosive esophagitis, gastrointestinal bleeding, and esophageal cancer.

GERD nonpharmacological therapies are: 
  • losing weight, 
  • raise head as high as 15-20 minutes during sleep, 
  • stop smoking and drinking alcohol, 
  • reduce eating habits that can stimulate an increase in stomach acid, 
  • avoid eating within 3 hours before bedtime.

GERD pharmacological therapies are
  1. antacids; 
  2. prokinetic (metoclopramide); 
  3. histamine H2 receptor antagonists (cimetidine, famotidine, ranitidine); 
  4. PPI (esomeprazole, omeprazole, lansoprazole); 
  5. baclofen. 

However, the advantages and disadvantages of using suppressor for a long time need to be considered.

Of all the pharmacological therapies mentioned above, PPI is the most effective drug in relieving complaints and curing esophagitis lesions in GERD. PPI works by inhibiting H +, K + adenosine triphosphatase in gastric parietal cells, so that gastric acid secretion is suppressed.

Various studies suggest that therapy using PPI has a higher cure rate and can reduce the recurrence rate greater than H2 receptor antagonist drugs. PPI can also reduce complaints or symptoms by up to 80%.

After establishing the diagnosis, start GERD treatment by administering a single dose of PPI every morning before eating for 2-4 weeks. If the complaint has not subsided, increase PPI dose to twice a day until the complaint disappears. Twice a day, therapy can be given for 4-8 weeks. After the complaint disappears, PPI no longer needs to be consumed routinely.

According to ACG, taking PPI agents for eight weeks is a therapeutic choice to reduce complaints and treat complications of GERD. The effect of PPI will be optimal if consumed 30-60 minutes before eating. Newer PPI drugs, such as esomeprazole, tend to have optimal times that are more flexible with meals.

Compared with other PPI class of drugs, esomeprazole is considered more effective in providing gastric pH stability for 24 hours so that it can help GERD patients who undergo Ramadan fasting avoid complaints or complications of GERD.


GERD Treatment during the Ramadhan

To date, there are no specific clinical guidelines or consensus regarding the management of GERD during the fasting month. In the nonpharmacological aspect, GERD treatment for patients who are fasting is the modify of food types and compositions.

Patients need to avoid spicy foods and high fat, chocolate, and caffeine, especially when breaking the fast. It is also important not to eat food in 2-3 hours before bedtime.

Adjustment of GERD pharmacological therapy during  Ramadan is quite difficult due to the need for an interval time between the administration of the drug and start eating. The most optimal PPI therapy is given 20-30 minutes before breakfast. This therapy will be suboptimal if not consumed according to the right time because it can interfere with the effectiveness of the drug, especially in terms of dealing with GERD complaints.

Therefore, the selection of PPI agents that are less frequent is the recommended alternative therapy. The provision of PPI agents with the frequency of giving twice a day is considered equivalent to the provision of the latest PPI agents with the frequency of giving once a day.

Effectiveness of Esomeprazole in Overcoming GERD

A study by Miner P et al. examined the comparison of several PPI drugs (esomeprazole, lansoprazole, omeprazole, pantoprazole, and rabeprazole) against intragastric pH of 34 patients suffering from GERD.

The average amount of intragastric pH can be evaluated for around 24 hours. On day 5, intragastric pH can be maintained> 4.0 for 14 hours with esomeprazole; 12.1 hours with rabeprazole; 11.8 hours with omeprazole; 11.5 hours with lansoprazole; and 10.1 hours with pantoprazole. 

In patients with intragastric pH> 4.0, the esomeprazole group also had a significantly higher percentage than the other PPI groups.  But, the frequency of side effects that occurred was the same in all intervention groups.

This study concluded that 40 mg of esomeprazole a day could control stomach acid more effectively than other PPIs. However, the limitations of this study are the small sample size and did not examine the therapeutic effect on complaints and complications of GERD.

Kalaitzakis E et al. conducted a systematic review regarding the effectiveness of esomeprazole in dealing with GERD complaints and cures erosive GERD lesions, compared with other types of PPIs (lansoprazole 15 mg or pantoprazole 20 mg). This review stated that administering esomeprazole 40 mg once a day is more effective in maintaining intragastric pH compared to other types of PPI.

Several studies in this systematic review also stated that after 4-8 weeks of therapy, esomeprazole 40 mg once a day gives a cure rate of erosive esophagitis lesions greater than omeprazole 20 mg, lansoprazole 30 mg, and pantoprazole 40 mg once a day.

Conclusion
Scientific literature still does not show definite evidence of whether fasting during Ramadan will relieve the symptoms of GERD. However, with proper management, relieved GERD symptoms during the fasting month can be achieved. During the fasting month, patients should eat foods that are high in calories at dawn. Patients should also avoid foods that contain fat, chocolate, caffeine, and too spicy foods when breaking the fast and avoid eating food 2-3 hours before going to bed at night.

Esomeprazole, with a standard dose of 40 mg once a day, can be a drug of choice for consumed in the morning before dawn. Esomeprazole can maintain intragastric pH for a more extended period than other types of PPI. Moreover, esomeprazole can also improve erosive esophagitis lesions. This can help GERD patients who will be fasting during Ramadan to prevent complaints and complications of GERD during fasting.


References
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3. Seifi N, Hashemi M, Saffairan M, Hadi V, Raeisi M. Effects of ramadan fasting on common upper gastrointestinal disorders: a review of the literature. J Fasting Health. 2017;5(1):20-23. Doi: 10.22038/jfh.2017.20258.1075
4. Mardiah R, Makmun D, Syam AF, Setiati S. The effects of Ramadan fasting on clinical symptoms in patients with Gastroesophageal Reflux Disease. Acta Medica Indonesiana. 2016;48(3): 169-175.
5. Rahimi H, Travakol N. Effects of ramadan fasting on the symptoms of gastroesophageal reflux disease. Journal of Nutrition Fasting and Health. 2018;6(4):213-219.
6. The Indonesian Society of Gastroenterology. National consensus on the management of gastroesophageal reflux disease in Indonesia. Acta Medica Indonesiana. 2014;46(3):263-272.
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9. Graham DY. Optimal PPI Dosing for improving GERD Symptoms: is Timing Everything? Digestive Diseases and Sciences. 2019;64:4-6.
10. Miner P, Katz PO, Chen Y, Sostek M. Gastric acid control with esomeprazole, lansoprazole, omeprazole, pantoprazole, and rabeprazole: a five-way crossover study. The American Journal of Gastroenterology. 2003;98(12):2616-2621.
11. Kalaitzakis E, Bjornsson E. A review of esomeprazole in the treatment of gastroesophageal reflux disease (GERD). Ther Clin Risk Manag. 2007;3(4):653-663.

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