Concerns about long term acid suppressive therapy

Physicians hate acid. But,  hey, who doesn’t hate acid? It burns things. It corrodes. It’s that after-pizza punishment.

We prescribe antacid medications by the ton in this country, not because people’s stomachs have developed increased acidity, but because people in our modern society are generally overweight, like to eat large meals, and prefer fatty foods and things like alcohol, chocolate, and tobacco, all of which tend to worsen acid reflux.

Physicians like to prescribe many different types of antacids because the patients like them and there are no perceived down sides (except cost). In particular, we prefer the so-called, proton pump inhibitors (PPIs) like omeprazole (Prilosec), lansoprazole (Prevacid), esomeprazole (Nexium), pantoprazole (Protonix), and rabeprazole (Aciphex) because PPIs are the most potent inhibitors of gastric acid secretion available are very effective treatment of moderate to severe gastritis, reflux, and peptic ulcer disease. So of course, if PPIs are good enough for the serious gastric illnesses, then they must be great for just about everything else! Right?

Proton pump inhibitors are prescribed  for even the slightest bit of heart burn or dyspepsia even though there is no good evidence for the effectiveness of intermittent use of PPIs for the treatment of the occasional over-eating  syndrome or that they are better for mild conditions than over-the-counter Tums, Pepcid, or Zantac.

PPIs are also heavily used in the hospitalized patient, especially those in the ICU, where various conditions like sepsis, hypotension, hypovolemia, stress, medications, and increased intracrainal pressure are risk factors for the development of gastritis and ulcers. Often the PPI therapy follows the patient home from the hospital and continues to be prescribed long after the original need for it has been forgotten.

There have been concerns about long term acid suppressive therapy, but until recently there has not been much hard data on the risks. That has now changed with the addition of two studies appearing in the archives of internal medicine.

  • If used within 14 days of the initial infection, PPIs increased the risk of recurrent Clostridium difficile infection in hospitalized patients from 18 to 25%. Especially in patients over 80 and on antibiotics (for other infections).
  • Long term (> 7-8 years) use of PPIs was associated with about a 25% increased risk of fractures of the spine, wrist, and forearm in postmenopausal women 50-80 years old compared to only an 8% increased risk with the use of other antacids. Interestingly, there was no associated increased risk of hip fracture and there was little difference in the measured bone mineral densities of women on PPIs compared to those not on these medications.
  • Starting PPIs  within the preceding week was associated with an increased risk of developing pneumonia. This risk was not found with the use of antacids like Pepcid or Zantac.
  • There is limited data to suggest that PPI use may decrease absorption of iron, calcium, magnesium, and vitamin B12.
  • Several studies have suggested (thus far not definitively proven) that the use of PPIs decreases the effectiveness of clopidogrel (Plavix) when used to prevent a second cardiac event.

From 53 to 70% of prescriptions for PPIs are written for mild to moderate and intermittent conditions such as gastric reflux or dyspepsia for which the use of over-the-counter antacids may be safer, cheaper, and more than adequate. However, physicians must cringe at the idea of seeing a patient with mild, intermittent heart burn and simply tell them to stop eating large fatty meals and take Pepcid. If the patient takes the time to come for an expensive medical evaluation then they must get an expensive medication.

Thus it is said, the modern medical mantra: expensive is, as expensive does.

Chris Rangel is an internal medicine physician who blogs at RangelMD.com.

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  • http://www.MDWhistleblower.blogspot.com Michael Kirsch, M.D.

    Your points about therapeutic excess with PPIs could be applied to many medicines and other treatments and diagnostic testing. I entirely agree. The potential PPI consequences of C. diff, pneumonia and bone issues are assocated with PPIs, which is not proof of causality. I also assume that gastric acid production, the result of a few million years of human evolution, has functions other than to cause heartburn and generate income for gastroenterologists. Nice post, Chris.

  • David

    We are a country of fat-asses always looking for the easy way out. Take a pill to lose weight, take a pills for acid reflux, take a pill for cholesterol.
    How about eating a healthy diet and exercise.

    • maribel

      I work in an OR and most people coming in for a nissen fundoplication to treat GERD are overweight. and for an umbilical hernia repair. and for a gallbladder removal. These people should pay more for health insurance. Why not? Your car insurance premium goes up if you have a few accidents because you’re a greater risk. Tack it on like flood or earthquake coverage is to a homeowners policy. a gluttony rider.

      • mariel

        Maribel – Your comment about a “gluttony rider” is a symptom of a syndrome of demanding perfection from others. Stop pointing fingers. I suppose you NEVER leave the house without sunscreen, NEVER eat more than 2 grams of sodium a day, NEVER miss aerobic or weight training exercise. Oh, by the way – night shift work has been correlated with higher blood pressure. Please stop all your overtime OR work now.

    • http://www.aneurysmsupport.com/ Mike

      I agree David, people are always looking for the path of least resistance. I use to suffer from nightly heartburn, and I was overweight. When I started eating a healthy diet, exercising, and loosing weight the heartburn disappeared.

  • http://doctorstevenpark.com Steven Park, MD

    It’s important to note that PPIs and other anti-relfux medications don’t do anything to prevent true reflux. They only lower the acidity of stomach secretions. What comes up into the esophagus or throat is just less acidic juices, along with digestive enzymes, bacteria, and sometimes bile. It’s also been shown that these same contents can even reach the ears, sinuses and lungs. As you can imagine, this can be a major source of inflammation throughout the entire upper aero-digestive tract.

    The most common cause of true reflux in my opinion is an underlying sleep-breathing problem. Frequent or intermittent breathing pauses can create thoracic pressures that promote reflux all the way into the throat. I’m not even talking about apneas. Once these pauses last more than 10 seconds, they’re called apneas or hypopneas. Most people with laryngopharyngeal reflux disease will prefer to avoid sleeping on their backs, but oftentimes, it’s not geed enough.

    Be definition, all modern humans stop breathing occasionally, with the end extreme of this continuum called obstructive sleep apnea. Due to our smaller jaws and dental crowding, there’s just not enough room for our tongues, especially when on our backs (due to gravity), and when in deep sleep (due to muscle relaxation).

    It’s no surprise that inefficient sleep arises and this can promote weight gain, which leads to more breathing pauses. However, it always begins as an anatomic/structural problem, rather than being an obesity problem. I see many young, thin and fit people who stop breathing 10 to 25 times per hour but not officially have obstructive sleep apnea.

    Having people avoid eating or drinking alcohol within 3-4 hours of bedtime can help many people, but not all.

    http://doctorstevenpark.com

  • http://brucesmallsurveys.typepad.com/ Bruce Small

    David: I suffer from GERD and related asthma, so I take Prilosec. I have those symptoms despite eating healthy, I exercise a lot, I work outside carrying equipment, and my BMI is 24. My blood pressure is low, and my total cholesterol is rock bottom.

  • http://minochahealth.typepad.com/gut/stop-heartburn-gerd-acidreflux.html doc

    The PPI “revolution” has been instigated by pharmaceutical companies through generously paid “thought” leaders and eaten up by gullible providers so much so that it is thought to be akin to candy. Some of the seemingly “harsh” comments are probably being generous. Our society is full of contradictions. We want cadillac health care but don’t want to pay for even Yugo care. We want pharmacological solution to the life’s problems. Studies indicate that almost half to 2/3rd of people taking long term PPI are taking those for largely unapproved and unproven reasons or indications.

  • David

    Not saying my comment applies to everybody, it is just out of frustration from dealing with so many patients who refuse to change their ways.

    • gzuckier

      Might it not be due to billions of dollars spent by very skilled practitioners to relentlessly induce these folks to consume the very junk that is killing them? See also tobacco use.

  • Natalie Sera

    I understand the reasons for not using PPIs for mild or intermittent heartburn, but if I don’t use them, I have severe heartburn 24/7, whether I’ve eaten or not. I’m not obese, and I don’t have a hiatal hernia. I can’t live on Tums, and I can’t think of anything else to do. Maybe I just have to take the risk.

  • Eduardo Alvarado

    It is a worrying issue everywhere. In my country, Peru, PPIs are used everywhere: many rounds prescribe it for EVERY hospitalized patient (!), or for patients takin multiple medications (even if they are not associated with gastric ulcers).

  • http://doctorstevenpark.com Steven Park, MD

    Natalie,

    Chances are, you probably can’t (or prefer not to) sleep on your back, right? Take a look at my previous response on this post. Many young, thing people who don’t snore can have severe sleep-breathing problems, without it being obstructive sleep apnea. Some even have low blood pressure or cold hands or feet. One of both of your parents probably snores a lot, right?

    There are effective ways of treating your GERD, without medications. Take a look at my articles on my website at http://doctorstevenpark.com. I describe my sleep-breathing paradigm in my book, which talks about these issues.

  • HJ

    “Take a look at my articles on my website at http://doctorstevenpark.com. I describe my sleep-breathing paradigm in my book, which talks about these issues.”

    Doing research on the internet helps prevent being prescribed an unnecessary medication.

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