There are a lot of questions now about the class of acid reflux medications called proton pump inhibitors (PPIs). PPIs include Prilosec (omeprazole), Nexium (esomeprazole), Prevacid (lansoprazole), and Protonix (pantoprazole). As acid reflux and stomach ulcers are common health conditions, many people take these medications. There have been several news stories raising concerns about these medications and many patients coming to see me in the office ask me about these drugs,
Why do people take PPI medications? Common reasons to take PPI medications include:
Acid reflux – Medication reduces stomach acid, and hence helps the symptoms of burning and discomfort.
Stomach ulcers- By reducing stomach acid, the PPI helps ulcers heal. Can also prevent recurrent ulcer bleeding in people that need to take blood thinners and medications like aspirin or ibuprofen (NSAIDs)
Upper abdominal pain (also known as dyspepsia)- medication for a short duration can relieve discomfort in the upper gut.
Barrett’s esophagus– reduced acid helps eliminate damage to esophagus tissue.
There are some clear health benefits to a PPI medication. Acid reflux can be associated with a condition call Barrett’s esophagus which can lead to esophagus cancer. Severe issues with acid reflux can cause pain, sleep disturbance, and poor quality of life. Stomach ulcers can cause internal bleeding.
So what are the risks?
A study in the journal JAMA Neurology (JAMA Neurol. 2016;73(4):410-416. doi:10.1001/jamaneurol.2015.4791) raised concerns that PPI use may be associated with dementia. The researchers obtained data on patients in a German health insurance plan and compared the rates of dementia on patients that took PPI to patients that did not take PPI. They did find that there was a weak statistical association with higher rates of dementia in patients on PPI medications. The issue with this study is that the patient’s on PPI medications in the study also had higher rates of stroke, heart disease, and use of multiple medications which can also cause dementia. These sort of research studies need to be interpreted with caution. A correlation does not equal a cause. You can ask my children to tell you about this. If you wear the green Packer jersey and they win this week, it does not mean that the Packers will win again next week if you wear the same jersey. Correlation does not equal cause. (Reference: 2016 NFC Championship game)
What should you do if you are on a PPI?
The most important thing to do would be to talk with the doctor prescribing the medication. If you are taking over the counter PPI medications, you should consider discussing your symptoms with a doctor. Even though I do not think the study on dementia was well designed and valid, I do like that the study has opened many discussions and has encouraged patient’s to ask questions. “Why am I taking this medication, doc?” is a question you need to know the answer for every pill bottle in your medicine cabinet.
For patients with GERD, I typically advise them to try and go off PPI medication and see how they feel. I advise this more for cost and simplicity; not due to concerns about dementia. If frequent issues with reflux return, then resuming the PPI for 2-4 weeks at a time for treatment tends to control the symptoms. This works for most patients. For patients that have issues with symptoms multiple times a week whenever they are off PPI, long term use may be indicated.
For patient’s with Barrett’s, it is advisable to stay on the medication as Barrett’s can cause cancer.
For patient’s that take blood thinners and have had issues the stomach ulcers in the past, there is a clear benefit to remaining on the medication.
What is rebound reflux?
Sometimes stopping PPI medication abruptly can cause what is called a rebound reflux. After long term PPI use, patients can have a temporary increase in reflux symptoms. This will typically resolve with time. Sometimes weaning the dose of the medication or changing to every other day dosing first can help with rebound. Using milder over the counter antacids can also help with this while coming off PPI.
My advice is in line with the American College of Gastroenterology’s recommendations. For more information:
http://acgblog.org/wp-content/uploads/2016/05/Loren-Laine-Long-Term-PPIs-AJG-04262016.pdf