Recent studies suggest that if you have IPF (idiopathic pulmonary fibrosis), that you may not perceive the GERD (reflux) that you have, and that this acid reflux may cause the fibrosis to progress. Ask for proper testing and treatment to see if you are one of the almost 80% of IPF patients who have reflux, often silent reflux.

1. Do You Believe in Reflux:
Idiopathic Pulmonary Fibrosis
Patricia Raymond MD FACG
Gastroenterology Consultants, Virginia Beach

2. It’s funny, but you really
never think much about breathing.
Until its all you ever think about.
Tim Wilson

3. What is
Idiopathic Pulmonary Fibrosis?
Chronic, progressive fibrotic disorder
of the lower respiratory tract.
Affects about 128,100 people in the
United States
48,000 new cases diagnosed annually
40,000 people die each year due to
IPF, the same as from breast cancer
(this statistic is pre-new drugs)
Up to 80% of folks with IPF
have GERD

4. What is GERD?
Gastroesophageal Reflux Disease
Increased acid, bile, gastric
contents moving up the esophagus
Typical symptom: burning in
chest
May cause spasm in lungs (asthma)
May lead to microaspiration and
fibrosis
Possible cause of, or
worsening of, IPF

5. You may not know you have GERD
Typical symptoms: heartburn,
chest pain, ‘acid brash’
Classic symptoms of GER
(heartburn, acid regurgitation)
were poor predictors of
increased esophageal acid
exposure among patients with
moderate to severe IPF.

6. IPF & GERD Rx
N=4 newly dx IPF and GERD, who chose
to be treated solely with anti-acid therapy
were followed up regularly with pulmonary
function tests (PFTs) over a period of 2 to 6
years.
Anti-acid GER therapy was administered
using proton-pump inhibitors and/or
fundoplication. Adequate suppression of
acid GER was ascertained by 24-h
esophageal pH monitoring.
PFTs stabilized or improved while their
conditions were maintained with adequate
treatment for acid GER. All patients were
alive at the last follow-up, and none
manifested an acute exacerbation of IPF or
needed treatment for respiratory problems
during this period.
Sole treatment of acid gastroesophageal reflux in idiopathic pulmonary fibrosis: a
case series. Raghu G, Yang ST, Spada C, et al.
Chest. 2006;129(3):794.

7. IPF & GERD Rx
One patient, after 4 years stable,
deteriorated coincident with poor
daily PPI use in 5th year. Stabilized
again year 6.
Another patient initially
deteriorated until taking PPIs as
directed.
Conclusion: More clinical studies
are needed to determine whether
adequate treatment for increased
acid GER in part improves the
outcome of patients with IPF.
Sole treatment of acid gastroesophageal reflux in idiopathic pulmonary fibrosis: a case
series. Raghu G, Yang ST, Spada C, et al.
Chest. 2006;129(3):794.

8. Maybe GERD doesn’t cause IPF, but…
Reviewed published reports linking IPF and
GERD 1980-2010.
319 publications, 22 of them met the entry
criteria
Relationship between GERD and
idiopathic pulmonary fibrosis (IPF) 14
articles; systemic sclerosis (SSc) in 6 articles;
mixed connective tissue disease (MCTD) in
2 articles
Prevalence of GERD and/or esophageal
dysmotility to be higher in patients with
different types of ILD as compared with
those without ILD [Evidence B].
Among patients with IPF, 67-76%
demonstrated abnormal esophageal acid
exposure off PPI treatment.
Systematic review: the relationship between interstitial lung diseases and
gastro-oesophageal reflux disease. Hershcovici T, Jha LK, Johnson T, et al.
Aliment Pharmacol Ther. 2011 Dec;34(11-12):1295-305. Epub 2011 Oct 17.

9. Maybe GERD doesn’t cause IPF, but…
No relationship was demonstrated
between severity of GERD and
severity of IPF [Evidence B].
Correlation between the severity of
ILD and the degree of esophageal
motor impairment in patients with SSc
and MCTD [Evidence B].
Causal relationship between GERD
and idiopathic pulmonary fibrosis
cannot be established.
There is scant evidence about
antireflux therapy in idiopathic
pulmonary fibrosis patients.
.
Systematic review: the relationship between interstitial lung diseases and
gastro-oesophageal reflux disease. Hershcovici T, Jha LK, Johnson T, et al.
Aliment Pharmacol Ther. 2011 Dec;34(11-12):1295-305. Epub 2011 Oct 17.

10. Say hello
to your
esophagus

11. GERD: It’s not only the acid
N=30 IPF patients, 1999-2006 UCSF
Esophageal manometry, and 24-hour dual
sensor ambulatory pH monitoring
20 of 30 (67%) patients had abnormal
esophageal reflux.
Typical reflux symptoms, although more
common in those with reflux, were not
reliable as a screening test (sensitivity 65%,
specificity 71%).
65% low LES pressure
50% abnormal peristalsis (vs 10% without
GERD)
In 9 (30%) patients, acid refluxed into the
proximal esophagus for over 1% of the
study time. Gastroesophageal reflux in patients with idiopathic pulmonary fibrosis
referred for lung transplantation. Sweet MP, Patti MG, Leard LE, et al.
J Thorac Cardiovasc Surg. 2007;133(4):1078.

12. GERD: It’s not the acid
Most patients with idiopathic
pulmonary fibrosis have pathologic
reflux.
Symptoms do not distinguish
between those with and without
reflux.
In these patients, reflux is
associated with a hypotensive lower
esophageal sphincter and abnormal
esophageal peristalsis, and often
extends into the proximal
esophagus. Gastroesophageal reflux in patients with idiopathic pulmonary fibrosis
referred for lung transplantation. Sweet MP, Patti MG, Leard LE, et al.
J Thorac Cardiovasc Surg. 2007;133(4):1078.

13. Why does GERD matter?

14. IPFs with
treated
GERD
live longer.

15. N=204
34% with GERD symptoms
45% with history of diagnosis of GERD
47% used GERD medications
5% has surgery for GERD (Nissan
fundiplication)
The use of GERD medications was an
independent predictor of longer survival
time.
The use of GERD medications was
associated with a lower radiologic fibrosis
score.
These findings further support the
hypothesis that GER and chronic
microaspiration may play important roles in
the pathobiology of IPF.
Gastroesophageal reflux therapy is associated with longer survival in patients with
idiopathic pulmonary fibrosis. Lee JS, Ryu JH, Elicker BM, et al.
Am J Respir Crit Care Med. 2011;184(12):1390.

17. GERD Rx in Placebo Patients in IPF
Trials: An Unintentional Study
Looked at three studies of IPF, at the patients who
received placebo N=242 patients
124 (51 percent) were taking a proton-pump
inhibitor (PPI) or H2 blocker at enrollment.
Patients taking a PPI or H2 blocker at baseline had
a smaller decrease in FVC at 30 weeks (-0.06 L,
95% CI -0.11 to -0.01) than those not taking anti-
acid treatment (-0.12 L, -0.17 to -0.08; difference
0·07 L, 95% CI 0-0.14).
These data suggest that GERD treatment could be
beneficial in patients with IPF and support the
previous reports suggesting that abnormal acid
gastroesophageal reflux contributes to disease
progression. However, controlled clinical trials of
acid reflux treatments in IPF are needed.
Anti-acid treatment and disease progression in idiopathic pulmonary fibrosis: an analysis of
data from three randomised controlled trials. Lee JS, Collard HR, Anstrom KJ, et al. ,
IPFnet Investigators Lancet Respir Med. 2013;1(5):369.

18. “However,
controlled clinical trials
of acid reflux treatments
in IPF are needed.”

19. Heck No.

22. What to do?
GET DIAGNOSED:
Ask your GI, Internist (GP or
FP) or Pulmonary doc to order a
24 hour pH test
ON MEDS if you are taking a
PPI (Prilosec, Protonix,
Aciphex, Nexium , Dexilant…)
to see if fully suppressing the
acid
On no acid reduction meds if
we have not established you to
have GERD
(if your test is ordered at SPAH, I will be assigned to
read the test)

23. What to do (2)?
Take your meds, EVERY DAY,
even if you don’t feel heartburn.
Lifestyle modifications:
Elevate HOB
Avoid late meals, large meals,
fatty meals
Sugar free candies or gum
(increased saliva flow)
Antireflux diet (no acidic
foods, no foods that relax the
LES)

24. Whenever I feel blue,
I start breathing again.
L. Frank Baum

25. "Do You Believe In Reflux"
Do You Believe in Magic
The Lovin’ Spoonful
1965

26. Do you believe in reflux, in lung fib-ro-sis
How the acid can worsen your longterm
prognosis
And it's reflux, if any acid is risin'
Even without symptoms, there's no
compromisin'
Even mild reflux cannot be dismissed
If 'Keep on Breathing's first on your bucket list

27. If you believe in reflux, start on PPIs
Add a 24 hour pH probe if you're really
wise
Just listen, you may have mild heartburn
But it'll progress to a point of no return.
Although you wish I'd run away to
Timbuktu
IFP and reflux can make you feel so 'blue'

28. Do you believe in reflux?
Do you believe like I believe?
Do you believe like I believe?
Do you believe in reflux?

30. Patricia Raymond MD FACG
Gastroenterology Consultants, Virginia Beach
757-523-9755 x 2320
Nurse: Ms Debbie Miller LPN
1925 Glenn Mitchell Drive, Suite 102,
Virginia Beach
(Sentara Princess Anne Hospital Campus)

31. References IPF & GERD
1. Tobin RW, Pope CE 2nd, Pellegrini CA, et al. Increased prevalence of gastroesophageal reflux in patients
with idiopathic pulmonary fibrosis. Am J Respir Crit Care Med 1998; 158:1804.
2. Raghu G, Freudenberger TD, Yang S, et al. High prevalence of abnormal acid gastro-oesophageal reflux in
idiopathic pulmonary fibrosis. Eur Respir J 2006; 27:136.
3. Sweet MP, Hoopes C, Golden J, et al. Prevalence of delayed gastric emptying and gastroesophageal reflux
in patients with end-stage lung disease. Ann Thorac Surg 2006; 82:1570; author reply 1570.
4. Schachter LM, Dixon J, Pierce RJ, O'Brien P. Severe gastroesophageal reflux is associated with reduced
carbon monoxide diffusing capacity. Chest 2003; 123:1932.
5. Lee JS, Collard HR, Raghu G, et al. Does chronic microaspiration cause idiopathic pulmonary fibrosis? Am
J Med 2010; 123:304.
6. Pashinsky YY, Jaffin BW, Litle VR. Gastroesophageal reflux disease and idiopathic pulmonary fibrosis. Mt
Sinai J Med 2009; 76:24.
7. Bandeira CD, Rubin AS, Cardoso PF, et al. Prevalence of gastroesophageal reflux disease in patients with
idiopathic pulmonary fibrosis. J Bras Pneumol 2009; 35:1182.
8. Raghu G, Yang ST, Spada C, et al. Sole treatment of acid gastroesophageal reflux in idiopathic pulmonary
fibrosis: a case series. Chest 2006; 129:794.
9. Hershcovici T, Jha LK, Johnson T, et al. Systematic review: the relationship between interstitial lung
diseases and gastro-oesophageal reflux disease. Aliment Pharmacol Ther 2011; 34:1295.
10. Sweet MP, Patti MG, Leard LE, et al. Gastroesophageal reflux in patients with idiopathic pulmonary fibrosis
referred for lung transplantation. J Thorac Cardiovasc Surg 2007; 133:1078.
11. Lee JS, Ryu JH, Elicker BM, et al. Gastroesophageal reflux therapy is associated with longer survival in
patients with idiopathic pulmonary fibrosis. Am J Respir Crit Care Med 2011; 184:1390.
12. Lee JS, Collard HR, Anstrom KJ, et al. Anti-acid treatment and disease progression in idiopathic pulmonary
fibrosis: an analysis of data from three randomised controlled trials. Lancet Respir Med 2013; 1:369.