Long Term Use of Acid Suppressors

Jul 27, 2017

By Trevor Shewfelt, Pharmacist at the Dauphin Clinic Pharmacy

It's Shark Week! If you don't know what Shark Week is, what's wrong with you? Do you mean to tell me you go outside during our beautiful Manitoba Summer instead of watching Discovery Channel? How are you going to find out who is fastest, Michael Phelps or a Great White Shark? Are serial killing Great Whites stalking us all? What about a shark - crocodile show down? Okay, pop quiz hot shot. What is deadliest? A cow, a snake or a shark. A cow is deadliest by far. Twenty people per year in the USA are killed by cows, 6 from snakes and 1 from a shark. Hmmmm. Despite the hype, the shark is less deadly than the cow? Does that mean not everything in the media is what it seems? What is more likely, dying falling from a ladder or dying in a plane crash? Plane crash right? They are in the news all the time. Nope. Odds from ladder fall is 1 in 2.3 million and dying in a plane crash is 1 in 11 million. Ladder death is almost 5 times as likely as plane crash death.

"Long-term heartburn medication use tied to higher risk of early death." That was a recent CBC headline and it had tons of people running scared to the pharmacy to ask about it. What was buried in the middle of the article was: "What that really translates to is the if 500 patients took the medication for about a year, then there would be one excess death that could be attributed to using this class of medication called PPI." 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 and then at their risks.

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 likely is it PPI's will cause problems? The study CBC quoted said 1 in 500 extra deaths per year with long term use. What does that mean? That sounds scary, but let's look at a non-death statistic. How likely is it our next governor general will be divorced? Our next Governor General will be Julie Payette. She speaks 6 languages, has 18 honorary degrees and is an astronaut. What are the odds she will be divorced? The odds of an astronaut being divorced is about 1 in 16. Still, have you ever heard of a divorced governor general on the news? One in 16 still sounds like it is really unlikely that Julie Payette will be divorced, right? Julie Payette has been divorced twice. People will look at 1 in 500 chance of death and believe it is definitely going to happen to them. People will look at a 1 in 16 chance of an astronaut being divorced and think that is very unlikely especially if she is going to be a governor general. People often do not assess risk well.

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.

Two other PPI problems keep being asked about in the pharmacy. 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.

What is more likely a President of the United States who attended Harvard or a male between 18-49 being afraid of spiders? Current President Trump aside, more than 25% of American Presidents attended Harvard. The odds are 1 in 3.58. The odds of a male between 18-49 being afraid of spiders is 1 in 83.33. It is way more likely that the President attended Harvard, than a random male on the street being afraid of spiders. Now back to Shark Week. I really need to know if we are under invasion from Hammerheads!

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.

We now have this and most other articles published in the Parkland Shopper on our Website. Please visit us at www.dcp.ca

Shark Week - https://www.discovery.com/tv-shows/shark-week/

CBC - Long Term Heartburn medication use tied to early risk of Death - http://www.cbc.ca/news/health/heartburn-proton-pump-inhibitor-death-1.4189603

BMJ Open Study - http://bmjopen.bmj.com/content/7/6/e015735

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

Odds of dying - https://www.livescience.com/3780-odds-dying.html

Things more likely than plane crashes http://www.travelstart.co.za/blog/6-ridiculous-things-more-likely-to-kill-you-than-a-plane-crash/


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