By Eric R. Wollins, MD
However, recent studies have shown that taking PPIs could pose serious side effects and even put your health at risk. To sort out these latest findings and learn more about the proper use of heartburn medication, we turned to Eric R. Wollins, MD, Chief of Gastroenterology for MAPMG in Northern Virginia.
The study that made headlines all over the world appeared in the British Medical Journal. It linked the use of PPIs to early death and found that the risk increased the longer people used these drugs. As a regular user of PPIs, should I be worried?
We should be very cautious about how we interpret the findings from this study. This was an observational study over nearly six years that examined the health records in the U.S. Veterans Affairs system of new users and non-users of acid suppression therapy.
One limitation of this study was that the patient population was homogenous: mostly older, white, male U.S. veterans. In addition, this study did not include information on cause of death – and thus we don’t know why and how patients in this study died. Since observational studies inherently increase the possibility that there may be other associations, we need to be very careful about extrapolating these results into the general population.
That said, this study and others – which have found associations between extended use of PPIs and kidney disease, dementia, and stroke, for example – do indicate that we should be looking closely at our prescribing practices. I do think it’s fair to say that while PPIs offer a clear benefit, they are overprescribed and sometimes inappropriately prescribed.
What is the proper use of PPIs?
PPIs have many indications for their use. Specifically, PPIs are very effective for the treatment of chronic heartburn, which is also known as GERD or gastroesophageal reflux disease. When appropriately prescribed, PPIs should be taken 30 minutes to one hour prior to breakfast (and dinner only if prescribed for twice daily use). Patients should take the lowest dose possible in order to alleviate their symptoms, and for some, this may be a once daily dose.
PPIs are most effective when taken daily to prevent future episodes of heartburn symptoms. They are less effective when used on an as-needed basis or for the acute and immediate relief of heartburn symptoms.
Patients with other indications to take a PPI, like esophagitis (inflammation of the esophagus) or a gastric ulcer, may require a short duration of treatment of only eight weeks and may not need long-term or chronic therapy.
Every patient is different and thus it is important to discuss your particular indication and course of treatment with your primary care physician, who may ultimately refer you to a gastroenterologist.
The bottom line is that PPIs have been around for nearly 30 years and have been shown to be very effective in treating most acid-related disorders, including chronic heartburn. Furthermore, when appropriately prescribed, their benefits are likely to outweigh their potential risks.
Is it absolutely necessary to treat chronic heartburn?
Yes. Left untreated, chronic heartburn can result in serious long-term complications. When stomach acid repeatedly washes up into the esophagus, it can cause inflammation that can cause bleeding, ulcerations, and even stricturing (or narrowing) within the esophagus.
In a small percentage of heartburn patients, long-term exposure to excess acid can lead to a pre-malignant condition known as Barrett’s esophagus. GERD has also been linked to several respiratory conditions including pneumonia, asthma and chronic cough, and even laryngitis.
Does everyone who suffers from heartburn need to take a PPI?
No. These drugs are intended for patients with chronic heartburn: people who experience typical heartburn discomfort on most days throughout the week.
For those with more occasional or intermittent symptoms, I suggest patients start with evaluating heartburn triggers within their diet. Acidic foods (citrus fruits and even grapes and apples) are common culprits for increasing the production of stomach acid. Spicy food and tomato-based foods may also exacerbate GERD symptoms. I recommend that patients take a trial-and-error approach by avoiding one of the many trigger foods to see if that makes a difference in their symptoms. Avoidance may ultimately be the best medicine.
While increased production of stomach acid is one cause of heartburn, another cause is more anatomical and relates to a problem with the musculature of the lower esophageal sphincter (LES). If the LES opens too often or doesn’t close tightly enough, stomach acid can seep into the esophagus and cause burning. Some foods and substances are well known to cause the LES to relax. These include alcohol, tobacco, chocolate, peppermint, and caffeine. Avoiding these can decrease the chances that the LES will relax and thus decrease your chances for developing symptomatic heartburn.
The good news is that often a small dietary or lifestyle change can make a big improvement in symptoms.
Are there medications other than PPIs that can be effective in treating heartburn?
For patients with intermittent heartburn or for those who may be hesitant to begin a course of PPIs, we often suggest a H2 receptor blocker. These medications target a substance called histamine and blocking this will reduce the production of acid within the stomach. Some commonly used H2 blockers include Pepcid, Zantac, and Tagamet. These are effective at treating heartburn and specifically may be helpful for treating acute and/or nocturnal heartburn symptoms.
Some patients with mild symptoms also have success using chewable antacids like Tums. Such antacids usually combine aluminum, magnesium, or calcium with hydroxide or bicarbonate ions to quickly neutralize stomach acid.
Whether you find relief for your chronic heartburn by changing your diet or through medication, the important thing is not to let it go untreated. Talk to your doctor to determine the safest and most effective course of treatment for you.
For more information about heartburn and its treatments, visit the MAPMG health resource page.