Long Term Use of Acid Suppressors
Mar 8, 2017
By Trevor Shewfelt, Pharmacist at the Dauphin Clinic Pharmacy
Oh what a tangled web we weave, when we first learn… where Reston is. The Neepawa Bantam Female team opened with a lop-sided loss 6 - 0 to Wawanesa. My favorite goon, Emily Shewfelt, decided to get on the score sheet in the penalty box instead of the goals and assists ledger. This is Emily's second year playing for Neepawa as there aren't enough Bantam aged girls in Dauphin for a team. Neepawa bounced back with a 3-0 win over Carman. Then they lost a 2-1 squeaker against the eventual Silver Medal winners, Brandon, in the semi-finals. The Bronze Medal game was pay back against Wawanesa. The game started well with a Neepawa lead 1-0. Wawanesa tied it up half way through the third. Then with 18 seconds left, I saw the game end in a way I don't think I've seen before.
Walter Scott said what a tangled web we weave when we first practice to deceive. I not quite saying the latest proton pump inhibitors or PPI's stories in the news are deceptions, but they might be misleading. PPI's have names like omeprazole, losec, esomeprazole, nexium, rabeprazole or pariet. People have been coming into the pharmacy and asking me if they should stop taking them. The short answer is no. Proton pump inhibitors are very effective and very safe. Let's look at what they do.
Proton pump inhibitors or PPI's are very good at suppressing the acid that your stomach produces. Because they reduce stomach acid, they are very useful for treating a variety of conditions. We use them to GERD (gastro-esophageal reflux disease) or heart burn, stomach ulcers, acid over production and to protect the stomach from medications like NSAIDs that can cause ulcers. They work so well that they make up over half of all drugs sold for stomach problems and represent a $20 billion dollar market. In 2012 14.9 million patients in the USA received 157 million prescriptions for proton pump inhibitors (PPIs). The problem is if we use PPIs for too long, they may start causing problems.
How long is too long for PPI use? Of course, that depends on the patient and the condition. Usually with GERD or after treating a patient with antibiotics for a stomach ulcer, we only want someone on a PPI for 8 weeks. Sometimes if a patient is in the hospital and ends up in the Intensive Care Unit or ICU, they are put on a PPI to prevent stress ulcers. In this case, the PPI should often be stopped before the patient leaves the hospital. There are some people who are going to need PPI's for a long time. People who produce way too much acid, people who have erosive injury to their esophagus and people who are on the pain killer's called NSAID's may all need long term PPI treatment. However, even in these cases, we want to use the lowest dose possible.
What happens if someone is on a PPI for too long? Well the evidence is mounting that a few problems can pop up. To begin with after someone takes a PPI for more than 3 months, they have a good chance of getting rebound acid hypersecretion. That means if we suddenly stop their PPI, their stomach will produce lots of extra acid. This will encourage the patient to start the PPI again. The best way to deal with this over secretion is to slowly decrease the PPI and then switch the patient to a weaker acid pill like ranitidine and then slowly reduce the ranitidine.
The next problem is breaking bones. The evidence isn't conclusive, but it seems that people who use PPI's in high doses for over 1 year are more likely to break bones. The experts aren't completely convinced this is a real effect yet or not. One of the theories why PPIs might affect bones is that with less stomach acid a person absorbs less calcium and thus their bones get weaker.
Another potential PPI issue is Vitamin B12 deficiency. Stomach acid is needed to cleave the Vitamin B12 we eat from the dietary protein it is attached to so it can be absorbed. It is estimated that 5-15% of people over 50 may have a Vitamin B12 deficiency. Vitamin B12 deficiency can lead to dementia, neurologic damage, anemia, and other complications. In the December 11, 2013 JAMA, Lam et. al. looked at a database without about 26,000 patients in Northern California with B12 deficiency and about 180,000 without B12 deficiency. They did some fancy math on the database and determined that people with B12 deficiency were more likely to have had been prescribed 2 years or more of PPIs or another acid blocker called an H2 receptor blockers, than those without a B12 deficiency. This is not definite proof that PPIs cause Vitamin B12 deficiency, but it is another reason we should be cautious about long term PPI use.
An interesting relationship exists between PPI's and pneumonia. It looks like people on PPI's are more likely to get pneumonia than those who are not. One theory is that when the stomach is less acidic, there are more bacteria in it. These bacteria can cause pneumonia with the right conditions. However this PPI - pneumonia link is controversial and needs further study.
Two PPI problems have made the news lately. One is PPI's cause kidney problems and the other is PPI's cause dementia. The kidney disease link is stronger. There was a very large study called the Atherosclerosis Risk in Communities study in which 10,439 patients were followed for 13.9 years. Those on PPI's were 50% more likely to get chronic kidney disease. Although this was a large, well done study, it wasn't a double blind placebo controlled one. Because chronic kidney disease is fairly common, more study would be needed to confirm the PPI-kidney disease link isn't a fluke. The link between PPI's and dementia is not as strong. The theory says PPI's might effect how amyloid plaques are made in the brain and how that might lead to Alzheimer's disease. One study people are talking about that looked at dementia and PPI's was published recently in JAMA Neurology. It is a controversial study, though. The first problem with the study was the patients they looked at had "dementia". Dementia in this study was a very broad and poorly defined term. Only Alzheimer's disease has these Amyloid plaques that some people think PPI's might effect. Only 2.7% of people in the "dementia" study had confirmed Alzheimer's disease. So the fuzzy definitions lead to fuzzy conclusions. The study also didn't look at common risk factors for dementia like alcohol use, family history of dementia and high blood pressure. So although a link between PPI use and dementia was found, it really needs more study to see if this is a real effect or not.
It is good when media outlets report on potential side effects of medications. And don't think they are trying to deceive people. But people shouldn't get the impression that proton pump inhibitors or PPI's are unsafe. They are still arguably one of the safest medications around. And if you are on a PPI, don't stop it without talking to your doctor. Some patients may get ulcers in their stomachs or erosions in their esophagus without their PPI. But like all medications, we should keep people on PPI's at the lowest dose for the shortest time possible.
There was 18 seconds left in the Reston Rink. Emily's Neepawa team was tied with Wawanesa. There was a scramble in front of the Neepawa goalie and huge pile of kids. The ref blew his whistle. He skated to the Neepawa bench. He said one of the Neepawa players put her hand on the puck in the crease. He gave a penalty shot to Wawanesa. They scored. The bronze medal slipped through our fingers. It was such a good game. It was such a weird ending. I'm sure there was a mini-explosion of SnapChat use as the girls told the world about their disappointment. Were we deceived by the ref, or was it a legit call? I have no idea. I guess there is always next year.
The information in this article is intended as a helpful guide only. It is not intended to be used as a substitute for professional advice. If you have any questions about your medications and what is right for you see your doctor, pharmacist or other health care professional.
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JAMA article on Vitamin B12 and PPI's - http://jama.jamanetwork.com/article.aspx?articleid=1788456
CBC - PPI's and kidney damage - http://www.cbc.ca/news/health/heartburn-drugs-kidney-damage-1.3994789
JAMA article on PPI Side effects - http://archinte.jamanetwork.com/article.aspx?articleid=2481153&resultClick=3
CBC article on PPI Side Effects - http://www.cbc.ca/news/health/proton-pump-inhibitors-1.3458585
Medscape article on PPI's and Dementia - http://www.medscape.com/viewarticle/859438