Doctors explain the benefits and risks of proton pump inhibitors
At one point, Dana Connell’s physician told her osteoporosis could be a side effect from taking a proton pump inhibitor (PPI) to manage her stomach pain, but that was it, says the 56-year-old Oak Park resident and college professor.
“I had terrible — at times, debilitating — stomach pain, and my previous physician never really treated it,” she says. She switched doctors, was immediately diagnosed with reflux and put on Nexium, a PPI.
“I had been taking Nexium for 10 to 15 years,” Connell says. “It was great — an easy pill to take and almost no stomach pain. Fast forward to about six months ago when new literature on PPIs came out, and my doctor wanted me off of Nexium.”
PPIs reduce the amount of acid produced by glands in the stomach. They’re commonly used to relieve symptoms of frequent heartburn and gastroesophageal reflux disease (GERD). Yet new research suggests that suppressing stomach acid may alter gut bacteria in a way that promotes liver injury and progression of some types of chronic liver disease. Another study suggests an increased risk of chronic kidney disease due to the use of PPIs.
About 6 to 15 percent of the general population use PPIs — such as Prilosec, Nexium and Prevacid — and the research is making many reconsider taking the drugs. But some Chicago doctors are saying that’s a big mistake and the benefits of PPIs may outweigh the risks outlined in the research studies.
“In general, the use of PPIs for treating the symptoms of GERD is safe and effective,” says Anthony Altimari, MD, general surgeon at Northwestern Medicine Central DuPage Hospital in Winfield. “These recent studies are concerning but not a reason to stop the medications.”
Why proton pump inhibitors work
“PPIs work by blocking an acid pump in the cell also called a proton pump,” says Ece Mutlu, MD, professor of gastroenterology at Rush University Medical Center. “Considering that these acid pumps are most concentrated in the stomach cells, PPIs mostly affect the stomach. They thereby reduce stomach acidity.”
And they work exceedingly well, because they block the end route of acid production.
Side effects from PPI use are infrequent, Mutlu says, and the research results are associative — meaning that a direct cause-and-effect hasn’t been proven. “It is inappropriate to conclude that the major cause of these health issues are PPIs,” Mutlu adds.
While the research should not be simply dismissed, patients should consult their doctor before making drastic changes, says Neil Sengupta, MD, a specialist in gastroenterology at UChicago Medicine.
While there are some risks associated with taking PPIs, he says, patients may be doing themselves more harm than good if they stop the drugs. And in some cases, a separate underlying condition may benefit from PPI use.
“For example, someone who has a history of heart disease and is on chronic ibuprofen because they have arthritis likely needs to be on long-term PPI therapy — independent of if they’re feeling well or not — because that PPI is preventing them from developing an ulcer,” Sengupta says. “However, for people who have uncomplicated reflux and are feeling better, then a decision should be made in conjunction with their healthcare provider to focus on lifestyle maneuvers and progressively try to come off the PPI.”
If a patient does not treat their reflux disease, they might be putting themselves at an increased risk of esophageal or laryngeal cancer, stricture formation, anemia, worsening asthma, chronic cough, sinusitis, inner ear infections, tooth enamel loss and burning tongue syndrome, says Michael Brown, MD, a gastroenterologist and specialist in digestive disorders at Rush University Medical Center.
“There’s a whole host of things that are associated with poorly treated reflux disease,” Brown notes.
PPIs can prevent upper GI bleeding, which is a risk for patients who are on blood thinners or anticoagulants. “I’ve had patients who discontinue [their PPI] and they’re on anticoagulants. They’ve had near life-threatening hemorrhages from stopping their proton pump inhibitor without talking to their doctor,” Brown says.
Patients who take a PPI should ask their physician if they have a medical condition that requires long-term PPI use, Sengupta recommends. If they don’t need a PPI for the long-term, they should discuss the lowest effective dose and length of treatment.
Lifestyle adjustments can help reflux. “Some of the lifestyle measures that can be implemented to reduce reflux include maintaining a healthy weight, reducing alcohol use, not eating in the late evening hours, not lying down immediately after eating and eating whole/real foods that one cooks and controls the ingredients in,” Mutlu says.
These recent studies are concerning but not a reason to stop the medications.”
Other options like H2 blockers might work for people with milder forms of reflux disease, Brown adds.
Surgery is another path for some types of reflux, as opposed to continued PPI use, Altimari says. “The medications do not stop reflux from occurring. They just neutralize the material that is coming up in the esophagus making it less irritating. Surgery is the only way to actually stop reflux if the reflux is from a malfunction of the valve.”
Open communication between the patient and doctor is always necessary to make sure that proper medication is used, Mutlu says.
“In terms of a PPI,” Mutlu says, “patients should always discuss with their doctor the benefit they are getting from the drug versus the risk of the drug and make a choice to use a PPI or not use a PPI based on the benefit-to-risk ratio.”
With her doctor’s approval, Connell chose Zantac (an H2 blocker) over a PPI. While it usually works for her, she still experiences discomfort daily.
“I try not to take the Zantac and sometimes can go a day without it,” she says. “I have Tums in every drawer at work, at home and in my backpack and take two at a time. It’s the worst for me at night, so I pop those Tums in my nightstand drawer. It’s honestly a daily struggle to find the right balance and what works.”
While the benefits and risks of PPIs may be a little hard to digest, individuals can collaborate with their physicians to find the best ways for them to reduce their stomach pain.