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A Handle on your Health: Acid Reflux & Treatment

Tuesday, July 30, 2019

Heartburn or acid reflex is no fun, especially if you like to eat like I do. Thankfully you have treatment options. Sometimes the treatment is simple and all you need to take is a Tums or Rolaids but sometimes you need long-term therapy with medicines like H2 Blockers or Proton Pump Inhibitors (PPIs).  While PPIs like Omeprazole have an encouraging safety profile, recently they have been in the news for some surprising health risks. Patients now come into the clinic concerned about taking these types of medicines.

What is the difference between these medicines? Tums and Rolaids act by neutralizing stomach acid on contact. They can be taken immediately for relief when you feel heartburn coming on. But as more acid is produced in the stomach you may have to re-dose yourself repeatedly. 

For longer acting relief, H2 blockers were invented. H2 blockers include medicines like Pepcid or Zantac. They work on histamine type 2 receptors to reduce acid production in the stomach. You may be thinking what are histamines doing in my stomach when usually we think of them as the cause of our seasonal allergy miseries. Histamine type 1 receptors are involved in allergies but the type 2 receptors secrete acid in the stomach. Pepcid acts to reduce the acid production and can produce relief within 1 hour of taking it and can last for a day. 

Cimetidine was the very first H2 blocker introduced back in the 1970s and it was a rockstar drug then. It was the first blockbuster drug and made GlaxoSmithKline millions of dollars. But it had lots of side effects so newer and better drugs were developed like Pepcid and Zanatc but also a whole new class of acid blockers called Proton Pump Inhibitors. 

The PPIs came out in the late 1980s and went on to eclipse the H2 blockers for the treatment of GERD (acid reflux) and similar illnesses. The PPIs work inside the stomach cells at the enzyme level to reduce acid production. Because of this mechanism of action they take a little longer to take effect but the results are a stronger more sustained reduction in acid. In other words, you wouldn’t take a PPI for heartburn relief now but rather you would take it to reduce your symptoms over days for ongoing relief of chronic symptoms.  

PPIs are great medicines for people with stomach ulcers or GERD. They are life changing for people with severe stomach acid diseases but as with any drug, there are often unwanted side effects. The worry with PPIs mainly comes from their use or overuse over years, instead of weeks or months. Recent studies have found an association between PPI use and the following: Low magnesium levels, Vitamin B12 deficiency, harmful bacteria in the gut, bone fractures, kidney disease, dementia, cardiovascular disease, cancer, pneumonia and premature death. It must be stressed here that an association does not equal a cause and effect relationship.  

Stomach acid is needed for the absorption of vitamin B12 so it makes since that if we lower the acidity we may reduce the absorption of B12 from our diet. It is clear that PPI use interferes with magnesium absorption too thus causing low magnesium levels in patients taking PPIs for more than a year. 

Stomach acid also creates an environment that many bacteria and viruses find inhospitable. So the theory is that with lowered stomach acidity some bacteria may be able to persist and grow thus causing infection like pneumonia and C-diff colitis. No evidence exists indicating PPIs are causing pneumonia or C-diff colitis, but there is an association. 

Hip fractures can be deadly, especially for our elderly population, and there has been a link found in PPI takers. It may be that the lower acidity is affecting the calcium absorption downstream in the small intestine. However, no definitive cause of osteoporosis from PPIs has been found. 

What about heart disease? The link between PPI use and heart disease mainly comes from the drug interaction with Plavix, which is a life saving “blood thinner” used in many patients with heart stents. PPI use may interfere with the activity of Plavix thus making it less useful thus putting cardiac patients at risk for redeveloping clogged arteries in the heart and having another heart attack. 

Newer studies, however, indicate that there is no increase in heart attacks with PPI use. People taking PPIs for years have about a 50 percent risk of developing reduced kidney function compared to others. It is unclear why and there may be other factors at work other than just taking the PPIs. 

Does taking PPI’s increase your risk of Dementia? Well the results are as foggy as dementia is. Some studies find an increased risk while others found no link. Time will tell.

Lastly people taking PPIs seem to die at higher rates. This was a VA hospital study and it showed people on PPIs versus people on H2 blockers died at a 25 percent higher rate. This isn’t meant to alarm you. The effect was small and again no cause was found with the PPI drugs themselves.

PPIs like Prilosec and Protonix are not bad drugs and when you need them, you need them. However, you don’t want to live on these drugs if you can help it. Make lifestyle changes to avoid having to take them if you can. Use the slightly weaker but effective H2 blockers when appropriate. Get regular check ups by your doctor to make sure you are not experiencing any of these side effects. Maybe you don’t add so much hot sauce next time to your chimichanga.

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Dr. John Turner is a family medicine and emergency medicine doctor with 25 years of experience. He is also the owner of My Primary Care Clinic and My Emergency Room 24/7 here in Hays County. Dr. Turner may be reached at 512-667-6087.

San Marcos Record

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