Acid reflux from anticholinergic drugs can show up hard in a woman who already has Sjögren's syndrome and Hashimoto's thyroiditis, because the drug relaxes the lower esophageal sphincter and slows down how fast her stomach empties. The proton pump inhibitor she was given next brought on tremor and disrupted sleep. Antigone, 70, can see the pattern by now, every new drug brought a new symptom. In this case study we explain why her body weight and how many times a day she eats affect the gastric phase, and why sleeping right after a meal makes her reflux worse.
The method behind this case
In IBSyncrasy we explain how medication, body weight, and the gastric phase connect to reflux episodes like Antigone's, and which changes are actually worth trying first. Buy IBSyncrasyWho Antigone is and what she already had going on
Her daily routine
Antigone is 70 years old. She weighs 68 kg (150 lb) at 157 cm (5 ft 2 in), which puts her right at the edge of the overweight range. She wakes up at 7:30am and starts the day with oatmeal in water, with slippery elm, raisins, and cinnamon. Around 11am she usually has a koulouri (a Greek sesame bread ring), and at 1:30pm comes her main meal of the day, lentils, chicken with rice, spinach rice, steak with potatoes, bean soup, or something oil-based depending on the day, and right after that she lies down to sleep. In the afternoon she has fruit with coffee and rusks, and in the evening something similar to lunch or pizza with tortilla and cheese.
She drinks about 6 glasses of water a day and gets no exercise. She's already on medication for high blood pressure and osteoporosis, two conditions that are being monitored steadily without any particular issue.
How the problem started
After a urodynamic test for incontinence, she was started on an anticholinergic drug. Within a short time she developed severe acid reflux, intense stomach pain, a dry cough, and unusually heavy drooling. She also started noticing that her ears kept getting blocked. An internist then prescribed the proton pump inhibitor Laprazol, but it made things worse, adding two brand new symptoms, an internal tremor and badly disrupted sleep.
At her next visit, she was advised to stop all of her medication, and little by little her symptoms eased off. Because of travel and stress, some of them are still around today, burping, an occasional dry cough, and the acid reflux itself.
What the rest of her history shows
Antigone already has a diagnosis of Sjögren's syndrome, Hashimoto's thyroiditis, and gastric antral vascular ectasia, also known as watermelon stomach. Her Lp(a) is significantly elevated, a separate cardiovascular risk marker being tracked alongside her reflux care. In her food diary, bread stands out at 7 days a week, potatoes at 4 days, and coffee every day with 1 to 2 cups, while fish shows up just once a week.
None of her six daily eating times have been evaluated so far as a possible strain on her stomach function, and the chain of medications that followed her incontinence hasn't been explicitly linked to her current reflux either.
- 1
Urodynamic test for incontinence
She's started on an anticholinergic drug.
- 2
First reactions
Severe acid reflux, stomach pain, dry cough, heavy drooling, and her ears keep getting blocked.
- 3
Laprazol prescribed
The proton pump inhibitor is added for the reflux, but brings on an internal tremor and badly disrupted sleep.
- 4
All medication stopped
Her symptoms gradually ease off.
- 5
Today
Burping, an occasional dry cough, and acid reflux remain to some degree, made worse by travel and stress.
Why acid reflux from anticholinergic drugs happens
What caught our attention right away in Antigone's history is the timing. Her reflux got noticeably worse within days of starting one specific drug, and the Laprazol that came next added two entirely new symptoms on top of it. That pattern led us to look at the mechanism behind each drug separately, so we could pin down exactly what was causing each symptom.
What an anticholinergic drug does to the lower esophageal sphincter
Anticholinergic drugs work by blocking the muscarinic receptors for acetylcholine, which is useful for calming an overactive bladder in incontinence, but that same acetylcholine also keeps up the muscle tone of the lower esophageal sphincter. In a study that looked at this kind of drug in healthy subjects, reflux increased significantly especially when lying flat, while standing upright was much more protective [1]. That explains why the same medication can stay fairly tolerable while someone is up and moving, and become far more of a problem the moment they lie down, which lines up exactly with Antigone's habit of lying down right after lunch.
The unusually heavy drooling she reported also has an explanation. When stomach acid reaches the esophagus, it triggers a reflex that increases saliva production, known in the literature as water brash, precisely because saliva helps neutralize the acid. It's a sign that reflux was already underway.
Why did a drug for incontinence make my reflux so much worse
Anticholinergic drugs act on the same receptors in several places throughout the body, including the bladder and the lower esophageal sphincter. In people who already have some degree of acid reflux, that relaxation of the sphincter can turn a mild, well-controlled issue into intense symptoms, especially when combined with lying down after eating. That's why prescribing anticholinergics to someone with known reflux usually calls for extra caution from the care team.
What the tremor and sleep disruption after the PPI meant
Laprazol belongs to the proton pump inhibitor class, a group of drugs that reduce acid production effectively, but long-term use has been linked to poor absorption of magnesium and calcium. In a recently published case, that exact combination, low magnesium and low calcium from prolonged proton pump inhibitor use, showed up as tremor and memory problems [5]. Magnesium plays a direct role in regulating neuromuscular excitability, so a drop in it can explain both the tremor and the sleep disruption Antigone described shortly after starting the drug.
The PPI was supposed to help me, why did I get tremor and stop sleeping instead
Proton pump inhibitors do genuinely help reduce acid, and they're often prescribed exactly when someone has acid reflux. But the longer they're used, the more likely it is that magnesium and calcium absorption in the gut gets affected. A drop in those two minerals can show up as symptoms that look completely unrelated to the stomach, like tremor, muscle irritability, or disrupted sleep.
How body weight connects to the gastric phase
Antigone's BMI sits at 27.6, right at the edge of the overweight range. Extra weight increases pressure inside the abdomen, which pushes stomach contents upward and makes reflux easier. In a large meta-analysis published in the Annals of Internal Medicine, overweight people had a 1.43 times higher chance of reflux symptoms compared to people at a normal weight, and people with obesity had 1.94 times higher odds, while the risk of erosive esophagitis was 1.76 times higher from a BMI of 25 and up [2]. In practice, in similar cases we've followed with this weight and reflux profile, gradual loss of even a few kilos usually comes before any other improvement in how often symptoms show up.
Reflux risk by body weight
Hampel, Abraham, El-Serag, Annals of Internal Medicine, 2005
Why frequent meals and sleeping after eating add to the strain
Every meal kicks off its own gastric phase, with hydrochloric acid secretion and a gradual emptying of the stomach that takes time to finish. Antigone eats six times a day, which means a new gastric phase often starts before the previous one has had a chance to wrap up. The result is a stomach that stays distended for longer, with more opportunities for the esophageal sphincter to relax temporarily.
Lunch at 1:30pm is followed almost immediately by sleep. When someone lies down soon after eating, gravity stops helping empty the stomach, and its contents stay in contact with the esophagus for much longer than in an upright position, the exact same positional effect described in the study on the anticholinergic drug [1], and confirmed again in a study on sleep position in people with reflux [6].
How Sjögren's syndrome, Hashimoto's thyroiditis, and gastric antral vascular ectasia converge
In Sjögren's syndrome, reduced saliva production means less natural neutralizing of the acid that rises into the esophagus, which prolongs how long the lining is exposed to it. That same dryness of the mucous membranes has also been linked to gastric antral vascular ectasia in people with Sjögren's [3]. At the same time, Hashimoto's thyroiditis has a documented link to slower gastrointestinal motility [4], adding one more reason for delayed stomach emptying on top of everything else.
Three conditions converging on the same reflux
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Less saliva to neutralize acid
Reduced saliva leaves acid in contact with the esophagus for longer, and is linked to gastric antral vascular ectasia.
Based on all of this, we decided to recommend fecal calprotectin, a test that has never been done in her case before. The autoimmune conditions she already has are linked, in a share of patients, to mild intestinal inflammation, and we want to see whether that's an extra factor adding to the overall picture.
What we expect the fecal calprotectin test to show
Fecal calprotectin is a marker of inflammation in the intestinal lining. In Antigone's case it has never been checked, despite her already having three autoimmune or autoimmune-related diagnoses.
If the result comes back elevated, it would mean there's an added inflammatory component in the gut, beyond the mechanical strain we described in her reflux, and that would shift how much weight we put on certain dietary changes. If it comes back normal, it would confirm that most of the problem sits in the mechanical function of her stomach and sphincter, the same mechanisms explained above.
What we recommend and how we think it will help
Out of all her original recommendations, we picked the five that most directly address the mechanics of her reflux, her weight, the gastric phase, sleeping after meals, and protecting her already sensitive mucous membranes.
Why we recommend soup for dinner
Liquid meals, like soup, shorten the gastric phase, because they need less mechanical breakdown and less hydrochloric acid to move on to the next stage of digestion. That means less strain on the stomach lining overnight, which matters especially in her case because of the gastric antral vascular ectasia, where the lining is already more prone to damage and bleeding.
How proper acid secretion depends on how she eats
The burping she still gets is usually a sign of unbalanced hydrochloric acid secretion during the gastric phase. We recommend chewing food thoroughly, so the stomach has less work to do, avoiding liquids during meals and for 60 minutes after, so the acid stays at full strength, and pairing animal protein with vegetables while limiting starch on the same plate. Because the gastric phase is heavily influenced by stress hormones, we also recommend eating without distractions, no phone or screens at the table.
Why we recommend avoiding sleep right after a meal
As we explained above, lying down right after lunch removes the help of gravity in emptying the stomach and extends how long acid stays in contact with the esophagus [1] [6]. We recommend she stays upright or seated for 2 to 3 hours after lunch, even if that means pushing her afternoon nap later.
Why we recommend cutting back on bread to bring her weight into a normal range
She eats bread 7 days a week and potatoes 4 days a week, two sources of refined carbohydrate that help keep her weight in the overweight range. As we showed above, losing weight directly lowers abdominal pressure and the risk of reflux symptoms [2]. We recommend she gradually swap out part of her bread for other sources of protein and vegetables at breakfast and in the afternoon.
Why we recommend more fluids up until 8pm
In Sjögren's syndrome, dry mouth gets worse when fluid intake drops off earlier in the day. Getting enough fluids in through the evening helps keep the mucous membranes hydrated, which is also linked to less inflammation in the gastric antral vascular ectasia [3], and it supports bone density too, which matters in her case because of her already diagnosed osteoporosis. We recommend she gradually increases her water intake up until 8pm, without drinking large amounts right before or during meals, for the reasons explained above.
Why we believe these changes will help
The five changes we're recommending treat her reflux as the result of specific mechanisms we mapped out in her history, her weight, how often she eats, her body position after eating, and the state of her already sensitive mucous membranes. The meta-analysis on weight and reflux we mentioned shows that even a small weight loss translates into a measurably lower risk of symptoms [2].
What this means for her day to day life
Sjögren's syndrome and Hashimoto's thyroiditis remain autoimmune conditions, none of our recommendations target those directly. But a large part of her reflux comes from factors that can change, her weight, how many meals she eats and what they're made of, and when she lies down. In similar cases we've followed with this combination of autoimmune conditions and mechanical strain, improvement in burping and dry cough usually shows up before any change on the scale.
We believe that combining a smaller gastric phase in the evening, gradual weight loss, avoiding sleep after meals, and enough fluids through the evening will help Antigone reduce how often and how intensely her symptoms show up, and we've seen this combination help in similar cases in practice.
If every new drug brought a new symptom
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Frequently asked questions
Anticholinergic drugs block the muscarinic receptors for acetylcholine and are commonly used for incontinence, overactive bladder, certain respiratory conditions, and some neurological conditions.
The same receptors they block in the bladder also exist in the lower esophageal sphincter. Blocking them relaxes the sphincter and slows stomach emptying, which makes reflux easier, especially lying down.
It's a condition of widened blood vessels in the lining of the stomach's antrum, which can cause bleeding and anemia. It's often linked to autoimmune conditions, including Sjögren's syndrome.
Extra weight increases pressure inside the abdomen and the risk of reflux. A large meta-analysis showed a higher risk of symptoms and erosive esophagitis in both overweight and obese people compared to people at a normal weight.
References
- Koerselman J, Pursnani KG, Peghini P, Mohiuddin M, Katzka D, Akkermans LMA, Castell DO. Different effects of an oral anticholinergic drug on gastroesophageal reflux in upright and supine position in normal, ambulant subjects: a pilot study. American Journal of Gastroenterology, 1999, volume 94, pages 925 to 930.
- Hampel H, Abraham NS, El-Serag HB. Meta-analysis: obesity and the risk for gastroesophageal reflux disease and its complications. Annals of Internal Medicine, 2005, volume 143, issue 3, pages 199 to 211.
- Goel A, Christian CL. Gastric antral vascular ectasia (watermelon stomach) in a patient with Sjögren's syndrome. Journal of Rheumatology, 2003, volume 30, issue 5, pages 1090 to 1092.
- Yaylali O, Kirac S, Yilmaz M, Akin F, Yuksel D, Demirkan N, Akdag B. Does hypothyroidism affect gastrointestinal motility? Gastroenterology Research and Practice, 2009, article 529802.
- Prabagar K, Wahan U, Sumanatilleke M, et al. Tremors and memory loss from hypomagnesemia and hypocalcemia secondary to long-term proton pump inhibitor use. Annals of Internal Medicine, Clinical Cases, 2026, volume 5, e250975.
- Khoury RM, Camacho-Lobato L, Katz PO, Mohiuddin MA, Castell DO. Influence of spontaneous sleep positions on nighttime recumbent reflux in patients with gastroesophageal reflux disease. American Journal of Gastroenterology, 1999, volume 94, issue 8, pages 2069 to 2073.