Acid that comes back up when you stop the medication

Why it comes back when you stop the medication: we've summarized the evidence

Key points in 30 seconds

1. Acid regurgitation and heartburn are common. Up to 30% of adults in Western countries are reported to have them.
2. Even if your endoscopy is clean, the symptoms are real. Even without damage to the lining, reflux itself and a sensitized esophagus create symptoms.
3. There's a mechanism, called rebound, behind symptoms coming back when you stop the medication. When 120 healthy people with no reflux symptoms at all took an acid-suppressing drug for 8 weeks and then stopped, 44% developed acid regurgitation and heartburn. In the group that took only a placebo, it was 15%.
4. So don't stop your medication on your own. Taking it and cutting down are for whoever prescribed it to decide. That said, concluding that "my body can't do without the medication" may be premature.
5. Outside of medication, three things have been confirmed with numbers: losing weight, avoiding late dinners, and raising the head of the bed. Acupuncture and Yukgunja-tang have been tested in cases not controlled by medication, and we've written their report cards below exactly as they are.

What we often hear

• "The medication definitely helps. But when I stop, it comes back within a week or two."
• "Do I have to take this for the rest of my life?"
• "They said my endoscopy was clean. So why is this happening?"
• "It comes up as soon as I lie down at night."

The stories of people who come in with reflux symptoms follow an order. First comes "the medication works well," then "but it comes back when I stop."

Both questions are fair. And for both, once you understand how this condition works, you can see which way the answer points.

Let me say this up front: this post is not telling you to stop your acid-suppressing medication. If anything, it's closer to a post that shows you, with numbers, why you shouldn't stop it on your own.

Here's what happens on your first day

• Whether there's anything to rule out first. If you have trouble swallowing, are losing weight, or have black stools, an endoscopy comes first. We start by asking about your testing history.
• We check the medication you take. We look at what you take and since when. We won't tell you to stop.
• We sort out when it comes up. Whether it's when you lie down at night, after eating, or whether it rises and falls with stress. This decides what you'll start doing today.

How common it is, and why the endoscopy is clean

Gastroesophageal reflux disease (GERD) is a condition where stomach contents flow back up into the esophagus and cause acid regurgitation or heartburn. It's common enough that up to 30% of adults in Western countries are reported to have it. An analysis pooling surveys from many countries found large differences between countries, but age 50 or older, smoking, taking anti-inflammatory painkillers, and obesity were consistently confirmed as risk factors.

This is where many people get confused. In a large number of cases, the symptoms are clear but the endoscopy shows no damage to the lining of the esophagus. This is called non-erosive reflux disease.

That's because even without damage to the lining, reflux itself and the sensitized feeling of the esophagus can create symptoms. It's the same structure we saw with functional dyspepsia. A normal test is good news. It doesn't mean the symptoms are fake.

Why it comes back when you stop the medication

Acid-suppressing drugs are an effective first-line treatment for this condition. Let me make that clear first.

The problem is that relapse after stopping is very common, and there's an experiment on this that surprised the field of gastroenterology.

A Danish research team gathered 120 healthy adults with no reflux symptoms at all. One group took a placebo for all 12 weeks; the other took an acid-suppressing drug for 8 weeks and then switched to a placebo. It was designed so that neither participants nor researchers knew who was getting what.

The results were clear. In the 4 weeks after stopping the drug, 44% of people who originally had no symptoms at all reported heartburn, acid regurgitation or indigestion. In the placebo-only group, it was 15%.

A mechanism was proposed too. When stomach acid is suppressed for a long time, the body compensates by increasing the signals that tell it to make acid. Then, the moment the drug is gone, that increased capacity to secrete acid is released all at once.

If this happens even in healthy people, then the relapse a person with reflux disease goes through after stopping may be a mix of the condition itself returning and this rebound.

The same thing happens with sleep. It's the same structure: what the body adjusted to fit the medication shows itself the moment the medication is taken away.

Two conclusions come from this.

First, suddenly stopping the medication on your own isn't a good approach. Taking it, stopping it and cutting down are things to decide in consultation with whoever prescribed it.

Second, the conclusion that "it comes back when I stop, so my body can't do without the medication" may be premature. Part of the relapse isn't your body being broken but a predictable rebound. That means there's room to plan the order of things.

What's been confirmed with numbers outside of medication

Lifestyle changes. These are often treated as advice along the lines of "eat less spicy food," but some items actually have measured evidence. Here's what a review of lifestyle intervention studies found.

Weight loss reduced the time the esophagus was exposed to acid in two randomized trials (from 5.6% to 3.7%, and from 8.0% to 5.5%, respectively). Eating dinner late increased acid exposure while lying down by 5.2 percentage points compared with eating early. Raising the head of the bed reduced acid exposure time from 21% to 15%. Quitting smoking in smokers of normal weight was also linked to fewer symptoms.

The conclusion is clear. If you're overweight, losing weight, and if your symptoms come at night, avoiding late meals and raising the head of the bed are evidence-based prescriptions. With this condition too, there are cases where treatments that cost nothing have the strongest evidence.

Acupuncture. There's a randomized trial of 30 people whose symptoms weren't controlled by a standard dose of acid suppressant. The group whose drug dose was doubled showed no meaningful change in symptoms, while the group that added acupuncture to the standard dose (twice a week for 4 weeks) had clear reductions in daytime and nighttime heartburn and acid regurgitation scores. What's worth noting is that it was designed as a direct comparison with the standard response of raising the dose.

Yukgunja-tang. There's a multicenter trial of 242 patients with non-erosive reflux disease not controlled by acid suppressants. It compared adding Yukgunja-tang to standard treatment versus adding a placebo, over 8 weeks.

Here are the results, honestly. On the most important measure, the symptom score, there was no difference between the two groups. However, among quality-of-life measures, the mental health score improved more in the Yukgunja-tang group, and a follow-up analysis reported improvement in some symptoms in older patients.

In short, this isn't evidence that it "clearly reduces symptoms across all patients." "There are signals in some patient groups and some areas" is where it accurately stands today.

The limits of this evidence

The size of the acupuncture trial. It was small, with 30 people, and since it was compared with a dose increase rather than sham acupuncture, the effect of acupuncture can't be separated from the effect of expectations. It's also a short-term, 4-week result.

Yukgunja-tang fell short on its main measure. The most important measure didn't reach the target. The mental health scores and the results in some patient groups are in the nature of side analyses, so they can't be read as definitive evidence.

Who the rebound study looked at. This trial was done in healthy people. How large a share rebound makes up in actual patients is a separate question. Relapse in patients of course includes the condition itself returning.

What the lifestyle studies measured. Much of the evidence on lifestyle interventions is about improvement in a physiological measure, acid exposure time, not in symptoms. Less acid exposure doesn't guarantee the symptoms go away.

The gap between a standardized formula and an individual prescription. The Yukgunja-tang tested was a standardized preparation. We can't say that a prescription adjusted for each person produces the same results.

What we make clear

We don't compete with medication. Acid-suppressing drugs are an effective first-line treatment, and while you take them, we have a separate role. The areas the medication doesn't address, such as lifestyle factors, stomach motility and heightened sensitivity, are our part.

And we don't inflate expectations. The report cards written above are everything we can tell you.

So these are the standards we use

First, we screen for warning signs. Trouble swallowing or pain when swallowing, unintended weight loss, repeated vomiting, black or bloody stools, anemia, and symptoms that started for the first time after middle age all call for an endoscopy first. The same goes if you haven't been tested or it's been a long time.

Second, we respect the medication you take. We won't have you stop it on your own. As the rebound data shows, stopping suddenly can make symptoms worse, and adjusting the dose is up to whoever prescribed it.

Third, we ask about the timetable of your symptoms. Whether it comes up when you lie down at night, whether it's worse after eating, whether it rises and falls with stress. If it comes up at night, there are evidence-based prescriptions in the head of the bed and dinner timing; if it's worse after eating, we look at eating speed and stomach motility; if it's tied up with stress, we look at that axis too.

Fourth, we treat weight and meal times as treatment. Apart from medication, these are the interventions confirmed to reduce acid exposure in numbers. We place them as prescriptions, not advice, and check at follow-up visits that you're doing them.

Fifth, we set the role of Korean medicine treatment only as large as the evidence. Adding acupuncture and herbal medicine for symptoms not controlled by standard treatment, especially in the type with a clean endoscopy, is the point the trials above addressed. There's no evidence to promise big results.

How we work

We check what to rule out and your history first. At your first visit we check for warning signs and your endoscopy history, and if you need a test and haven't had one, we first point you to a facility that can do an endoscopy. We check since when and how much acid-suppressing medication you take, and guide you to discuss any adjustment of it with whoever prescribed it.

We look at your type and your condition together. We sort out the timetable of your symptoms, check tension and tenderness in the pit of the stomach and belly with abdominal diagnosis, and look at your overall condition with tongue and pulse diagnosis. We check your weight and metabolic state with body composition and blood tests, and if weight loss is needed, we set a goal together.

We give lifestyle changes as a prescription. We give you the gap between dinner and bedtime, raising the head of the bed, a weight loss plan, and guidance on quitting smoking as concrete action items, and check them at follow-up visits.

Korean medicine treatment is added with a set role. We use acupuncture and electroacupuncture for uncontrolled symptoms and stomach motility, and put together herbal medicine based on abdominal diagnosis and test findings. If it's tied up with stress or sleep, we correct your rhythm too.

We set a period and take another look. We record your symptom score when treatment starts and measure again at a set point; if there's no response, we don't repeat the same treatment but rethink the direction. If needed, we recommend seeing a gastroenterologist.

Response to treatment varies from person to person, depending on the type of symptoms, accompanying factors such as weight and smoking, and the medication you take. The order in which we look at sleep and digestion is laid out in our reflux care page.

What changes

Not having to brace yourself when you lie down at night. That's the first change.

Next is the score. Since we wrote down your symptom score before treatment, you can see with your own eyes how much it has come down. You won't have to spend months thinking "maybe it's getting better, maybe not."

Please come see us if

• It comes back within a week or two whenever you stop the medication
• Your endoscopy is clean but your symptoms haven't changed
• It comes up when you lie down at night and disturbs your sleep
• You've been taking stomach medication for years

Bring the medication you take with you, as it is. We won't tell you to stop. We'll start by sorting out when it comes up, and decide what you'll start doing today.

Sources used in this post

Source	What the study looked at	Result
Eusebi et al., 2018	Pooled analysis of population surveys from many countries	Prevalence varies widely by country. Risk factors: age 50+, smoking, anti-inflammatory painkillers, obesity
Reimer et al., 2009	120 healthy adults with no reflux symptoms, double-blind	After stopping 8 weeks of acid suppressant, 44% developed acid-related symptoms (placebo 15%): rebound acid hypersecretion
Ness-Jensen et al., 2016	Review of 15 lifestyle intervention studies	Weight loss, avoiding late meals and raising the head of the bed reduced acid exposure (21%→15%, etc.)
Dickman et al., 2007	30 uncontrolled patients, directly compared with a dose increase	Adding acupuncture improved daytime and nighttime heartburn more than increasing the acid suppressant dose
Tominaga et al., 2014	242 uncontrolled non-erosive patients, multicenter double-blind	No difference on the main measure (symptom score). Improvement in mental health score and in some older patients

References

1. Eusebi LH, Ratnakumaran R, Yuan Y, Solaymani-Dodaran M, Bazzoli F, Ford AC. Global prevalence of, and risk factors for, gastro-oesophageal reflux symptoms: a meta-analysis. Gut. 2018;67(3):430-440. doi:10.1136/gutjnl-2016-313589

2. Reimer C, Søndergaard B, Hilsted L, Bytzer P. Proton-pump inhibitor therapy induces acid-related symptoms in healthy volunteers after withdrawal of therapy. Gastroenterology. 2009;137(1):80-87. doi:10.1053/j.gastro.2009.03.058

3. Ness-Jensen E, Hveem K, El-Serag H, Lagergren J. Lifestyle intervention in gastroesophageal reflux disease. Clinical Gastroenterology and Hepatology. 2016;14(2):175-182. doi:10.1016/j.cgh.2015.04.176

4. Dickman R, Schiff E, Holland A, Wright C, Sarela SR, Han B, Fass R. Clinical trial: acupuncture vs. doubling the proton pump inhibitor dose in refractory heartburn. Alimentary Pharmacology & Therapeutics. 2007;26(10):1333-1344. doi:10.1111/j.1365-2036.2007.03520.x

5. Tominaga K, Kato M, Takeda H, et al. A randomized, placebo-controlled, double-blind clinical trial of rikkunshito for patients with non-erosive reflux disease refractory to proton-pump inhibitor: the G-PRIDE study. Journal of Gastroenterology. 2014;49(10):1392-1405. doi:10.1007/s00535-013-0896-9

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If this is not the first time it's come back after stopping the medication, please come see us. We'll leave your medication as it is and start with what that medication doesn't address.

For questions or appointments, message us in English through the messenger at the bottom right of the page, or call +82-53-716-1175.