Sunday, March 30, 2014

The Pros and Cons of Acid -Suppressing Drugs

 The use of drugs such as Prilosec, Nexium and Prevacid is very common.   These drugs, known as Proton-Pump Inhibitors (PPIs) are available over the counter and in higher doses by prescription.  PPIs are the third largest class of drugs sold in the US, with over 10 billion in yearly sales.  A slightly weaker series of drugs known as H2 blockers are also available over the counter, as Tagamet, Pepcid and Zantac and in higher doses by prescription. 

These drugs are important in the treatment of peptic ulcer disease of the stomach, the prevention of esophageal cancer and in cases of severe reflux – known as GERD or gastroesophageal reflux disease.  People with frequent severe acid reflux are at greater risk of cancers of the vocal chords and throat; acid-suppressing drugs may play an important role in prevention. 

Obviously, these drugs have been beneficial to many. However, there are serious downsides to their overuse.  A study from the University of Washington found that women between 50 and 79 using PPIs were at increased risk of spine, forearm or wrist fractures, despite no decrease in bone mineral density or increased hip fractures.  Other studies have shown an increase in hip fracture with long-term use, and lessened calcium absorption.

Daily use of PPIs is associated with a 74% increase in Clostridium difficile infections in hospitalized patients, according to a Harvard study.  The gastrointestinal infections, with severe diarrhea, are very serious, can be fatal, and are difficult to treat. 

PPIs are also associated with an increased risk of hospital-acquired and community-acquired pneumonia.  By suppressing stomach acidity, pathogenic bacteria that are ordinarily killed by acid can be aspirated into the lungs.  H2 blockers may also have this effect, but to a lesser degree. 

Use of PPIs and H2 blockers for two years or more is associated with an increase in vitamin B12 deficiency, which can lead to anemia, neurologic problems and dementia, according to a study done at Kaiser Permanente.  The definitive study on low B12 levels and cognitive decline was done at Oxford University. 

PPI use is also associated with low magnesium levels, which can lead to muscle spasms and an irregular heart beat.

These findings present a dilemma.  There are obviously benefits of acid blocking drugs for people at risk for esophageal cancer, bleeding stomach ulcers, and severe reflux disease.  The problem is that many people are using these drugs for ‘convenience’, making it possible to eat large late dinners without suffering from reflux.  Some people are not sure why they are taking these drugs, once prescribed by a doctor.  The risks may well outweigh the benefits.   Here are some ways to prevent reflux discomfort without drugs.  Eat a smaller early dinner, avoiding foods that give you reflux, such as tomato sauce, chocolate, chiles and too much fat. You probably know your own triggers.  Don’t eat within 3-4 hours before bedtime.  Raise the head of your bed, or fix your pillows so that you can sleep sitting up if you feel GERD coming on.  Lose some weight if you are overweight – try Weight Watchers or a book on ‘volumetrics’, by Dr. Barbara Rolls.  Go to The National Weight Control Registry and read the success stories of people who have lost 30 pounds or more and kept it off.  You will find great ideas that can work for you.   

Get off PPIs slowly, as you may experience rebound stomach acidity for the first two weeks, before getting back to normal.   

Sadja Greenwood, MD, MPH   Check out past columns on this blog, and look at my novel, Changing the Rules, at local book stores and Amazon.