Rethinking the Continuous Use of Proton Pump Inhibitors

          

 

     A very large number of adult Americans take a class of drug known as a proton pump inhibitor.  A proton pump inhibitor, which I will henceforth call a PPI .  A PPI is a group of drugs which, with continued use effectively reduce a patient's stomach acid. (They do so by  binding with the enzyme H+, K(+)-ATPase, hydrogen/potassium adenosine triphosphatase, which is sometimes referred to as the proton pump.) The enzyme causes the parietal cells of the stomach to produce acid which is normally a positive situation in order to digest food.   There are a number of bonafide disorders in which this class of drugs is immeasurably beneficial.  Barrett's esophagus, peptic ulcer disease treatment,  Gastroesophageal reflux disease (GERD), and Zollinger-Ellison Syndrome are a few.  What used to be called an hiatal hernia or a sliding hiatal hernia also benefits from PPIs.    Infection with Helicobacter pylori, which is the causative organism to ulcers is generally treated with triple therapy, of which a PPI is an integral part.   It can also be used in babies, children and teens, on occasion.  It can be helpful in management of some of the symptoms of cystic fibrosis. It is also extremely beneficial in veterinary uses, for alpacas, horses, and other animals who may develop life threatening ulcers and gastrointestinal bleeding as a result of an injury or illness in another area.
                  However, in the US, an awful lot of people are on this drug because they are obese, and because obesity, particularly around one's middle increases pressure against the esophagus and makes sensations of severe heartburn much worse.   Packages of these drugs are designed to be administered for fourteen days, however a huge number of patients take these continuously for years.
              I noticed several years ago that every patient I have who takes PPIs continuously also has extremely low magnesium levels.  This is an issue because low magnesium is often a factor in heart rhythm disturbances, like atrial fibrillation.  Yet an awful lot of physicians were completely unaware of the link between PPIs and low magnesium or hypomagnesemia.
              The drugs which fall into the PPI class are listed here, first by its American trade name, and then in parentheses, by its generic name, because we have a number of readers worldwide.   The five drugs classed as PPIs are Prevacid (lansoprazole),   Prilosec (Omeprazole), Nexium (Esomeprazole), Protonix (Pantoprazole), and Aciphex (Rabeprazole)   In the United States, many of these are available OTC or over-the-counter.


The recommended doses of these drugs are:

 

• Esomeprazole: 20 to 40 mg once a day.
• Lansoprazole: 15 to 30 mg once a day.
• Omeprazole: 20 to 40 mg once a day.
• Pantoprazole: 40 mg once or twice a day.
• Rabeprazole: 20 mg once a day. In hypersecretory conditions, doses as high as 60 mg twice daily have been reported.

The doses will vary depending upon the use.


         This week several periodicals reported results from a study of PPIs in mouse and animal tissues.  It was found that PPIs increase a chemical messenger called ADMA (asymmetric dimethylarginine)   Higher ADMA levels can cause construction of blood vessels and may result in less blood being made available to the heart muscle.  This study did not indicate that PPIs decrease perfusion to the kidneys.   In addition, a Canadian study from 2011 suggested that PPIs may increase the incidence of heart disease the population who is taking them.

         What is the take away message here ?    First, if you are taking these drugs for Barrett's Esophagus or for a reason which was prescribed by your physician then don't stop taking it.  To do so could cause acid to backwash from your stomach to your esophagus, and over years could cause esophageal cancer.  Some people take PPIs to avoid inhaling  acid stomach contents while sleeping.  These people should continue to take these drugs as physician ordered.

Zantac is available OTC in the US and is also known as Ranitidine.

Cimetidine is Tagamet

         However, if you are a person taking this drug and you it allows you to eat extra fats and spicy foods and weigh more than you should, then you may wish to consider a temporary trial of a drug called Tagamet (Cimetidine) or Zantac (Ranitidine.)     If either of these drugs effectively manages your heartburn then this particular population of patients should probably switch from PPIs until more studies have been completed.
        Certainly, your choice of antacid and heartburn treatment and the DOSE of any treatment you use would be a really good discussion to have with your doctor.