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The overproduction of stomach acid and our sensitivity to it is one of the most common reasons people visit a doctor’s office.  Of course, many lifestyle choices contribute to that as well (overeating, obesity, smoking, alcohol use, to name a few).

Drugs that suppress acid production have been blockbusters for a long time.  In 1990 the first Proton Pump Inhibitor (PPI), Prilosec, was approved for use for the treatment of ulcers, acid reflux and esophagitis.  PPIs are now the 3rd largest pharmaceutical seller, accounting for 113 million prescriptions in 2012, and $14 billion of revenue for their makers.  When they were first marketed PPIs were promoted as having very few adverse effects, and that has largely been true for short term use.  But with the addition of 5 other PPIs (Prevacid, Dexilant, Nexium, Protonix, and Aciphex) and long term experience with the use of these drugs, we now know that there are some very serious risks of harmful effects.  We also know that longer use, higher doses and advancing age further accelerate these risks.  The risks include:

  • Hip fracture and fractures of the wrist and spine – This risk is even higher if you have diabetes or kidney disease.
  • Heart Disease – In addition to causing an overall 21% increase risk of heart attack, PPIs reduce the effectiveness of a very important heart medication called Plavix (clopidogrel).  Certain PPIs, like Protonix, increase the risk of heart attack by 80%!
  • Iron deficiency – this occurs because suppressing acid interferes with the absorption of iron.
  • Clostridium Difficile infection – this is an increasingly common cause of severe and sometimes life threatening diarrhea.  It turns out that the acid in our stomach kills the bacteria that cause this disease.
  • Pneumonia – again, acid kills bacteria, and when those bacteria can live in the gut it increases our risk of lung infection.
  • Stroke – just this month a new study has been released indicating a 21% increase in the risk of stroke from PPIs.
  • Kidney failure – a study in April indicated a 96% increase in the risk of kidney failure from these medications.

Startlingly, it is estimated that 70% of people taking PPIs are using them for a non-approved indication.  In addition, if you have been taking a PPI for a long time and you stop it, there may be a rebound over-production of acid, causing worsening symptoms and making it more difficult to stop.

What can be done?

  • If you have been on a PPI for more than a year, and most especially if you are over age 50 or have other chronic diseases, talk to your doctor about other treatment options.  It makes sense to try to get off the PPI if your doctor, NP or PA thinks it is safe.
  • If you have acid symptoms, lifestyle adjustment is the best treatment.  Stop smoking, reduce or eliminate alcohol, avoid food that triggers symptoms, lose weight, exercise, don’t overeat and get adequate sleep.
  • For symptoms that occur less than once a week consider old standbys like liquid antacids.
  • H2 blockers like Zantac (ranitidine) are likely less risky if a prescription is necessary.
Noah Nesin, MD

Dr. Nesin, Vice President of Medical Affairs for PCHC, is a family doctor with 30 years of experience.

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