GERD and Sleep Apnea: How They’re Connected

Quick Takeaways

• Obstructive sleep apnea (OSA) and gastroesophageal reflux disease
  (GERD) have overlapping risk factors and symptoms.
• Both OSA and GERD can disrupt your sleep.
• Treating OSA with continuous positive airway pressure (CPAP)
  therapy may be associated with fewer GERD
  symptoms.^19,20,21
• The connection between OSA and GERD isn’t clear, but it may be
  related to pressure differences in the chest and
  abdomen.⁴
• Treating both conditions may help improve symptoms and support
  overall health.

The Link Between GERD and Obstructive sleep Apnea

Obstructive sleep apnea (OSA) and gastroesophageal reflux disease
(GERD) are common health conditions that affect 936 million¹
and 784 million² people worldwide, respectively.

Recent research shows that these two conditions may be linked.
⁴ That means if you’ve been diagnosed with OSA, you might
struggle with acid reflux. And if you have GERD, you may experience
symptoms of OSA — such as daytime tiredness, nighttime choking or poor
sleep quality.³³

The good news? Both GERD and OSA can be managed with proper
treatment. Understanding the similarities can help you explain the
symptoms to your doctor, so you can get the support you need.

What these conditions are

Gastroesophageal reflux disease (GERD) is a digestive disorder that
happens when the muscles at the bottom of your esophagus, or food pipe,
don’t close completely. This allows stomach acid to flow backward into
your esophagus (a process called acid reflux), causing irritation,
heartburn and possible tissue damage.³

Obstructive sleep apnea (OSA) is a sleep disorder where you stop
breathing repeatedly at night.³⁴ This happens because the
muscles in your throat relax, collapsing your airway and stopping the
flow of air. Your brain wakes you up so you can breathe, resulting in
poor sleep quality.

For many people, these two conditions go hand in hand. In fact, 12%
of people with GERD also have OSA. Researchers are still exploring the
connection, but some believe that changes in pressure across your
stomach and airway during sleep could be partly to
blame.⁴

How one condition can affect the other

The link between OSA and GERD isn’t completely clear. One theory is
that when you have OSA, you might cough or gasp after each pause in
breathing. At the same time, your respiratory muscles have to work
harder as they try to move air in and out.⁵

These movements can put extra pressure on the ring of muscles (also
called the sphincter) at the bottom of your esophagus, causing it to
open. Coughing also creates pressure on the stomach, which can force
contents from your stomach back into your esophagus.⁴

Like OSA, GERD can also affect your sleep. When nighttime acid reflux
causes coughing or choking, it may wake you up and reduce sleep
quality.³

Shared risk factors

The clearest connections between obstructive sleep apnea (OSA) and
gastroesophageal reflux disease (GERD) are the shared risk factors:

• Obesity: People with excess weight have a higher
  chance of developing both OSA and GERD.⁴
• Age: The risk of OSA and GERD rises as you get
  older.⁴
• Anatomy: People with certain body structures
  could be at risk for OSA and GERD. For example, a hiatal hernia (which
  causes part of the stomach to push up through the diaphragm and into the
  chest) can affect the stomach valve and is more common in people with
  OSA.^6,7
• Lifestyle: Smoking, alcohol and certain foods
  can worsen the symptoms of OSA and GERD.³

How obesity can affect both sleep apnea and GERD

Obesity is one of the many factors that affect GERD and OSA. Excess
weight may cause a variety of changes in your body, some of which can
affect the risk or severity of your symptoms.

Some of the changes are physical. When you have excess weight, it can
lead to soft tissue in your neck and tongue that narrow the airway. The
added weight in this area can also contribute to airway collapse.
^8,31

If you have GERD, excess weight can put pressure on your abdominal
region. As excess fat pushes down on your stomach and the bottom of your
esophagus, it can open the sphincter (the ring of muscles at the bottom
of your esophagus) and force stomach acid upward.⁹

• Changes in your metabolism due to obesity can also affect OSA and
  GERD. GERD has been associated with metabolic syndrome,¹⁰ and
  sleep apnea has been linked to metabolic issues such as insulin
  resistance. The sleep disturbances that come with OSA may contribute to
  metabolic changes that increase the risk for conditions such as
  diabetes.¹¹

• If you’ve been diagnosed with OSA or GERD, your doctor may
  suggest healthy weight management as part of your treatment plan.
  Studies suggest that losing 20% of body weight may be associated with a
  57% reduction in sleep apnea events¹² and may help lessen
  GERD symptoms.¹³

While losing weight may help improve symptoms, it’s still important
to get treated for OSA. If you have obesity, weight loss may make OSA
treatments such as continuous positive airway pressure (CPAP) more
effective.³⁵

Symptoms and diagnosis

When your doctor diagnoses you with either obstructive sleep apnea
(OSA) or gastroesophageal reflux disease (GERD), they may not
automatically check for the other condition. However, if you’re
experiencing overlapping symptoms, you might want to ask about the
possibility that you have both disorders.

Obstructive sleep apnea and GERD overlapping symptoms

OSA and GERD may present overlapping symptoms, including:

• Choking or gasping while you sleep³³
• Sore throat or hoarseness in the morning³
• Poor sleep quality and daytime sleepiness³³

GERD symptoms that may occur alongside OSA include:³

• Heartburn or chest discomfort that gets worse at night
• Throat irritation or cough from acid reaching the higher parts of
  your esophagus

Different people react differently to each condition, which means you
may not have all of these symptoms.

Why diagnosis can be tricky

Because GERD and OSA have similar symptoms, doctors may not diagnose
both conditions right away. Sometimes, symptoms that appear related to
GERD may also be linked to OSA.

For example, if you have GERD, and wake up with a sore throat, you
might assume it’s caused by stomach acid irritating the soft tissues.
³ However, in some cases, throat discomfort may also be
related to sleep apnea if it causes you to sleep with your mouth
open.³⁶

If you’re concerned about sleep apnea, talk to your doctor about your
symptoms and getting tested. Your doctor may recommend you take a sleep
test to monitor your breathing overnight. You may need to spend the
night in a sleep lab or you might be able to take a test at
home.³⁴ Your doctor will examine the results to determine if
you have OSA.

If you’ve already been diagnosed with obstructive sleep apnea, you
can ask for GERD to be checked. This could be especially helpful if
you’re still experiencing acid reflux symptoms after starting continuous
positive airway pressure (CPAP) or another OSA treatment. To determine
if you have GERD, doctors may use a variety of diagnostic tests — such
as an endoscopy, an esophageal pressure measurement or a pH monitoring
test — to check how often stomach acid moves into your
esophagus.³

Impact on daily life

Obstructive sleep apnea (OSA) and gastroesophageal reflux disease
(GERD) can have a significant impact on your everyday life. In many
cases, that’s because both conditions can disrupt your sleep. You may
notice that you’re consistently tired during the day or that your energy
levels are low. The lack of quality sleep can also make it difficult to
focus or remember things.⁴⁰

The chronic sleep loss associated with OSA and GERD may also affect
your body. Studies show that getting less than seven hours of sleep per
night may be linked to stress, anxiety and depression.¹⁴
Daytime sleepiness may also make it dangerous to drive, increasing your
chances of getting into a car accident.³⁷

Risks of untreated sleep apnea and GERD

If OSA and GERD are left untreated, they may increase the risk of
long-term health issues, including stroke, heart disease and metabolic
disease.^15,16

GERD can also cause complications such as esophagitis(inflammation of
the esophagus). Over time, this may result in a narrowing of the
esophagus or gastrointestinal bleeding. ¹⁷

Another potential effect of untreated GERD is Barrett’s esophagus, a
change in the lining of your food pipe that may increase your risk of
esophageal cancer.¹⁷ And if you inhale the stomach acid that
backs into your esophagus, it may contribute to breathing issues and
inflammation in the lungs.¹⁸

Treatment and management

Whether you have OSA, GERD or both, getting treatment can help ease
your symptoms and reduce your risk of long-term complications.

How CPAP can help

Continuous positive airway pressure (CPAP) is highly effective and is
the most used and understood method for treating sleep
apnea.³⁸ Some studies suggest that CPAP may be associated
with fewer nighttime reflux symptoms in people with both OSA and GERD.
CPAP use has been shown to reduce nighttime acid reflux for people who
use it as directed. The positive pressure may help balance pressure in
your chest and airways, which could play a role in preventing stomach
acid from moving into the esophagus.¹⁹

In one study, people with both OSA and GERD who used their CPAP as
recommended experienced fewer acid reflux symptoms. ²⁰ Some
research suggests that consistent CPAP use may be associated with better
improvements in reflux-related symptoms. ^21,20 The same study
also showed that regular CPAP users were 42% less likely to suffer
nighttime heartburn symptoms compared with people who used CPAP less
often or not at all. ²¹

It’s important to note that everyone responds differently to CPAP
therapy. Some people with OSA tend to swallow air when using a CPAP
machine, which has been linked to more frequent reflux
symptoms.²²

Lifestyle changes

Your doctor may recommend lifestyle changes to help you manage the
symptoms of OSA and GERD. These might include:

• Sleep position. Side sleeping may help reduce
  the number of times you stop breathing with OSA.³⁹ If you
  also have GERD, sleeping on your left side with your head raised may
  help reduce reflux.²⁴
• Meal timing. Eating your last meal or snack of
  the day at least three hours before bedtime may help reduce GERD
  symptoms.²⁵ Early dinners can also help with OSA. Late
  dinners, on the other hand, have been shown to increase the number of
  breathing pauses at night.²⁶
• Diet. Following a GERD-friendly diet can help
  reduce reflux. It’s a good idea to avoid alcohol and foods with high
  levels of acid, spice, fat or caffeine.^27,32
• Weight loss. Losing excess weight may help
  improve the symptoms of both OSA and GERD.^12,13

Medicines and surgery

If you have both obstructive sleep apnea (OSA) and gastroesophageal
reflux disease (GERD), your doctor may recommend additional treatments.
This could include medicines that reduce stomach acid, such as:

• Antacids
• Proton pump inhibitors
• H2 blockers
• Potassium competitive acid blockers³

In some cases of severe OSA and GERD that do not respond to
less-invasive treatments, surgery may be an option. Anti-reflux surgery,
which can repair a hiatal hernia and tighten the end of your esophagus,
may help keep acid in your stomach and reduce reflux
symptoms.²⁸ People with OSA might consider
uvulopalatopharyngoplasty (UPPP), where a surgeon removes or reshapes
the tissues in the throat. Another option is a hypoglossal nerve
stimulation (HNS) implant, which moves the tongue forward to keep the
airway open.²⁹

Because obesity is closely linked to both OSA and GERD, your doctor
may discuss bariatric surgery as an option for weight management. This
surgery is typically recommended for people with a body mass index (BMI)
of 40 or higher. It may also be recommended for people with a BMI of 35
with other health conditions, such as sleep apnea.³⁰

Team-based care

Once you’re diagnosed with both OSA and GERD, it’s important to work
with doctors who specialize in sleep medicine and gastroenterology.
Working together, your doctors may be able to find a treatment that
works for you. You’ll likely need regular checkups to track the progress
with both conditions and adjust treatment plans if necessary.

To help your health care team, take notes about your symptoms,
medications and treatments. Sharing that information with all of your
doctors can help them make informed recommendations.

Although the link between obstructive sleep apnea (OSA) and
gastroesophageal reflux disease (GERD) isn’t fully understood, the two
conditions appear to be connected. If you have OSA or GERD, pay
attention to your symptoms. These disorders have overlapping risk
factors and symptoms, so it can be tricky to diagnose people who are
living with both.

If you think you might have OSA and/or GERD, talk to your doctor. The
right treatments may help ease symptoms and support your overall
health.

If you’re looking to learn more about your sleep, consider taking a
brief 3-5 minute sleep assessment.

Disclaimer: Obstructive sleep apnea and GERD are both medical conditions that require diagnosis and treatment by a doctor. This information is educational only and not a substitute for medical advice.

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