Steps one to three of GERD treatment summary—are they meant to be done sequentially, or do they overlap? Specifically, would you want to wait until someone is entirely off PPIs prior to introducing HCl, so complete step one prior to moving on to the next step?

Dr. Amy Nett: For people who can’t see, how we approach treating GERD, the first step is going to be reducing factors that promote bacterial overgrowth and low stomach acid; and then the second one is replacing stomach acid, digestive enzymes, and key nutrients; and then the third step here, the third piece of this, is restoring beneficial bacteria and a healthy mucosal lining, using things like probiotics and prebiotics. They don’t entirely need to be done simultaneously, I would say, because, in particular, you really want to get the beneficial bacteria and healthy mucosal lining back. For example, for restoring the healthy mucosal lining in the gut, one of the things I like to use is GastroMend. I will actually sometimes use GastroMend to help people get off of proton-pump inhibitors. A lot of times, people have had such a bad experience with reflux that they’re really just scared to come off their proton-pump inhibitors because they remember what the pain was and they don’t want to have that again. So what I’ll sometimes do is I’ll have someone start, for example, GastroMend and probiotics, and then once they feel a little bit more comfortable, I’ll have them start very slowly weaning off their proton-pump inhibitors.

I would agree that I don’t normally do acid replacement too much until we’ve lowered the proton-pump inhibitor dose, but some people, again, are going to do better having the digestive enzymes and acid replacement on board. So I don’t think these are necessarily sequential because I think some of these things are going to help. Weaning people off of proton-pump inhibitors can be difficult, both for you and for them. Sometimes using the strategies in step two and step three might actually help you with that step one, so I don’t necessarily think of these as sequential. There’s going to be some overlap. When you look at the summary table and you see step three is to restore the gut ecosystem, you won’t completely restore the gut ecosystem until they’re off of the PPIs, but really, as a matter of getting them off the PPIs, you’re going to have to rely a little bit on step two and step three there, as well, to help, and then you’ll sort of finalize step three once they are completely off.