If you have been taking potent acid-suppressing drugs [Losec (Prilosec in USA), Nexxium, Prevacid, Tecta, Dexilant or others] regularly for more than 8 weeks, you should talk to your doctor about whether you should continue taking them. Although indicated long-term for some conditions, recent studies have found that 40 to 55% of people are taking them for no diagnosed reason.
One factor that keeps people on these drugs, known as PPI’s (Proton Pump Inhibitors), is that many experience “rebound hyperacidity”, or increased production of stomach acid, when the medication is stopped. New guidelines have been created to help your doctor advise you how to quit these medications if they are no longer needed.
Although this class of drug has been available for over 25 years and is generally regarded as safe, with some being sold now without prescription, some problems have been associated with long-term daily use:
Decreased absorption of some vitamins and minerals (calcium, magnesium, vitamin B12 and possibly iron, and vitamin C) that need stomach acid for absorption.
Decreased bone density (due to decreased absorption of calcium) with associated increase in fractures of the wrist, hip and spine.
Increased muscle spasms (due to decreased magnesium)
Interactions with some drugs (clopidogrel [Plavix, taken to prevent blood clots], high dose methotrexate [used to treat cancer].
Increased growth of certain unfavourable bacteria in the digestive system (C. difficile, Traveller’s Diarrhea, Small Intestine Bacterial Overgrowth).
Increase risk of developing pneumonia (likely associated with increased bacteria in the digestive system).
“Observational” studies suggest an association of use of PPI drugs with increased cancers of the esophagus and stomach, dementia, chronic kidney disease and heart attacks. Observational studies do not prove the drugs cause these conditions, but they have created some concerns. Although recommended for preventing acid reflux in patients with Barrett’s Esophagus (scar tissue in the esophagus caused by long-term acid reflux, believed to be a precursor for cancer of the esophagus), one study observed increased rates of cancer in patients who took PPI’s daily. Hopefully, future studies will be done to determine whether these drugs are truly a cause of the observed increased risk.
A newly reported study done at University of Southern California has suggested a mechanism for multiple organ damage from acid suppressing drugs. PPI drugs block the pumping mechanism that pumps acids into the stomach but they found these drugs also block similar acid pumps in the tiny enzymatic “garbage disposal” lysosome sacks within other cells in the body, reducing the acid they need to function. This, they propose, allows waste to build up inside cells in the kidney, brain and lining of blood vessels, causing cells to age more quickly and dysfunction. This could explain how drugs designed to dramatically reduce acid in the stomach, could affect other organs. However, more research is needed – so far, this is just a theory.
Meanwhile, many people are taking these drugs for no documented reason and others may do just as well on a lower level acid suppressing drug such as an H2RA or Histamine-2 Receptor Antagonist [the ranitidine (Zantac)/ famotidine (Pepcid) family of drugs] that don’t have these side effects. Non-drug approaches can also be used to reduce acid reflux. These include diet and lifestyle changes, such as:
Eat smaller meals and don't eat late at night
Reduce weight (even 5-10% can make a difference)
Avoid tight clothing
Avoid "trigger" foods and drinks (keep a diary of which foods were eaten before episodes)
Ask your pharmacist or doctor to check your medications for any that might be aggravating reflux
The guidelines recommend lowering the daily dose, stopping, switching to “as needed” use, or changing to an H2RA to reduce acid, once a course of 4 to 8 weeks has been completed to heal an ulcer or esophagus damage from heartburn. Note that “rebound hypersecretion” of acid has been reported for up to 2 weeks when long-term PPI drugs are discontinued, that is difficult to distinguish from the original problem. Reducing the dose gradually and introducing non-drug strategies (diet/lifestyle changes) may help reduce symptoms on discontinuation of PPI’s. Click here for Mayo Clinic's lifestyle recommendations for reflux (GERD or GastroEsophageal Reflux Disease).
The detailed deprescribing guideline recommendations are available here.
