Heartburn or gastro-esophageal reflux disease (sometimes referred to as GERD) is quite common. It is estimated that more than 60 million Americans experience heartburn symptoms on a weekly basis.
The treatment of heartburn symptoms has become more simple thanks to the availability of over-the-counter (OTC) medications to treat this widespread condition. Three medication classes are available for prescription and over-the-counter treatment - proton pump inhibitors (PPIs), histamine H2 receptor blockers/antagonists, and antacids. Examples of PPIs include Prilosec, Nexium and Prevacid (and their store brand equivalents). H2 blockers that can be purchased OTC are Zantac and Pepcid (and store brand equivalents). Antacids are typically medications that neutralize acid, like Tums and Rolaids.
PPIs include drugs that affect the production of acid in the stomach by blocking a proton pump in the stomach thus reducing acid production. PPIs, one of the more popular classes of medications used to treat GERD, have come under recent review and may not be as safe as originally thought. However, some patients’ symptoms cannot be controlled effectively without these medications.
It is important to be aware of some of the potential concerns or potential side effects associated with long-term use of these medications. Many studies that report the potential adverse affects are that the associations are often weak and the data in different studies has been conflicting - that is, the results or findings are not always the same in different studies.
The potential adverse effects of PPI use range from interaction with other drugs, increased risk of infections, reduced intestinal absorption of vitamins and minerals, and more recently kidney damage, dementia and death. Specific potential concerns that have been associated with long-term PPI use include osteoporosis, hip fracture, Vitamin B12 deficiency, anemia, stomach (gastric) polyps, clostridium dificil infection, pneumonia, low magnesium levels, kidney disease and dementia. Recently, a well-publicized study suggested that long-term use was even associated with higher mortality or death.
A recent thorough review in the gastrointestinal literature quite capably summarized these potential issues. (J Gastroenterol Hepatol. 2017 Jul;32(7):1295-1302). The associations between these potential adverse effects were listed as weak, modest, consistent or uncertain. Specifically, the associations between these potential adverse effects were listed as consistent and modest for gastric polyps and kidney disease. The association of PPI use and adverse effects of low magnesium, B12 deficiency, increased fractures, clostridium dificil infection, pneumonia and gastric cancer were listed as weak. It was uncertain whether dementia was associated with PPI use.
Proton pump inhibitors are probably among the safest and most effective drugs prescribed today; however, in recent years, a wide range of possible adverse effects have been identified. As such, as with any long-term medication, other alternatives may want to be considered to control heartburn symptoms. Other alternatives to PPIs to reduce heartburn symptoms may include lifestyle changes. Weight loss, avoiding eating three hours before lying down, elevating the head of the bed and avoiding foods that trigger GERD symptoms can be helpful. A trial of a medication, like ranitidine (Zantac) or famotidine (Pepcid), may be considered as a means of “stepping down” the therapy.
PPIs are frequently overprescribed in many patients. If you are on one of these medications, it is a good idea (as we should do for all long term medications we are taking) that the clinical indication for continued PPI use be reviewed with your primary care provider or gastrointestinal provider to determine whether the treatment is still necessary and/or if alternatives exist.