Saturday, July 13, 2013

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.


BBC said...

I have no idea what you are talking about being as I take no drugs or meds.

JaneofVirginia said...

Keep eating properly ! Unfortunately, most adults in the US are taking some prescription medication, and if not, they re using something OTC.

BBC said...

Keep eating properly? Hell, I don't know what that means either, I just eat whatever I want to eat, just not very much of it. And at seventy years of age I don't give a crap what others think I should be eating.

BBC said...

OTC? Over the counter? Hell yeah, I put the beer on the counter, the clerk rings it up and I pay for it, she asks if I want a receipt and I say, "No, I tell everyone I steal this stuff." :-)

JaneofVirginia said...

BBC, You certainly must be eating properly for you ! LOL

Sunnybrook Farm said...

I don't take any drugs either. It doesn't sound logical to take this kind of medicine as eating properly and actually doing some manual work solves a lot of this kind of problem. I suspect that drinking a lot of sodas wouldn't help the situation.

JaneofVirginia said...

There are people who need this class of drugs to avoid erosion of their esophagus, esophageal cancer, and a number of other uses as described in the post. However, making it OTC and billing it as harmless had validated a lot of people taking it for whom it may have some negative long term effects. Glad you are well.

lotta joy said...

I've been on Nexium for 20 years and have severe osteoporosis. So, I started taking probiotics, due to all the tetracycline I'm on, and now I have heartburn.

JaneofVirginia said...

It's so good to hear from you ! I have missed you. PPIs can be valuable drugs for many situations. I am just asking long term users of these to have this discussion with their doctors.
You have been very missed ! Hope you are on the mend, my friend.

Linda said...

I took Prilosec for about a year because I had acid reflux. Then, I decided not to take them because I read that they interfere with absorption of nutrients. Now, I do not eat any chocolate late at night and have no caffeine. I am more aware of what I eat. However, due to low thyroid, I just cannot lose weight that I really need to lose. The doctor's appointment for the thyroid is still six weeks away.

JaneofVirginia said...

Yes Linda, It's true that some nutrients depend upon an acidic stomach environment to enhance absorption, and when we take PPIs regularly, we impede the absorption of these nutrients. I too only eat chocolate in the afternoon, never near bedtime. I was diagnosed with hypothyroidism after my third full term pregnancy when I was almost 30. I had not yet put on weight but nothing was working correctly. Once I was given full replacement thyroid I improved, but it took time for the adjustments to be made. I hope the six weeks until you see the endocrinologist goes quickly.