When Alison Huck of Shrewsbury, Mass., had a persistent cough in 1999, she thought she had pneumonia. She was actually diagnosed with reflux (sometimes called gastroesophageal reflux disease or GERD) and given a prescription for omeprazole 20 mg, twice a day, which the 50-year-old has taken religiously ever since.
Omeprazole is more commonly know as Prilosec and is part of a class of drugs called proton pump inhibitors (PPIs). Other brand names include Nexium and Prevacid. These drugs essentially shut down acid production in the stomach, which helps decrease acid reflux. (Drugs known as Zantac and Tagamet are called H2 blockers and are acid reducers, not inhibitors.)
In the past few months, however, two studies have found that PPIs may be linked to an increased incidence of chronic kidney disease and dementia, giving patients like Huck pause about their continued use. With about 15 million Americans taking PPIs, the news caught the attention of many, especially since PPIs have already been linked to magnesium deficiency, increased incidence of pneumonia and weakened bones.
In fact, it was low magnesium levels in patients that lead Johns Hopkins University School of Medicine kidney specialist Dr. Morgan Grams, to look into a possible connection between PPIs and chronic kidney disease.
Proton pump inhibitors (PPIs) have already been linked to magnesium deficiency, increased incidence of pneumonia and weakened bones.
“We know that lower magnesium levels are a risk factor for chronic kidney disease,” says Grams, whose study, published in JAMA Internal Medicine in January 2016, set off a firestorm of media coverage when it revealed that PPIs could increase the risk of kidney disease by 20 to 50 percent. But Grams specifies that this increased risk is more likely to occur in individuals age 70+ who may already be at risk. Still, ticking off another box on PPIs and their risks may have patients second-guessing their use.
What Is Acid Reflux?
Acid reflux or GERD is the rise of stomach acid into the esophagus, which causes heartburn. However, there’s another kind of reflux disease called laryngopharyngeal reflux or silent reflux. “Most people who have this don’t recognize it as an acid problem,” explains Dr. Jordan C. Stern, founder of Blue Sleep Center in New York City and a head and neck surgeon who specializes in sleep surgery and reflux treatment.
Rather than chest pain or indigestion, these people clear their throat a lot, may have voice problems such as hoarseness, and, because of the chronic irritation of their throat, have frequent throat infections.
If a patient has these symptoms, Dr. Prashanthi Thota, of the department of gastroenterology and hepatology at the Cleveland Clinic, refers that person to an ear, nose and throat doctor because of where the acid problem is occurring.
Risks Versus Benefits of PPIs
As with many medications, you have to weigh the benefits off PPIs against the risks. Regardless, you should speak to your doctor about how long you need them. “No one ever told me to stop taking them,” Huck says.
“There are very few patients who should be on PPIs on a lifelong basis,” explains Thota. “Those with Barrett’s esophagus [a precursor to esophageal cancer] need to be on PPIs. Barrett’s does not go away. What has been shown is that PPIs reduce the progression of Barrett’s to esophageal cancer.”
It was a diagnosis of Barrett’s esophagus in 2013 that led Pat Olsen, 66, to start taking Nexium. With the latest news about PPIs, Olsen, of Tinton Falls, N.J., would love to stop taking them but feels it’s in her best interest to stay the course.
“It’s scary to think I was so close to cancer and didn’t even know it,” she says. At the same time, “it’s way scary to think [PPIs] could be affecting my bones and putting me at risk for early dementia.”
Grams adds that PPIs can be a “lifesaving drug when used to prevent gastrointestinal bleeds, which can kill people.”
On the other hand, because PPIs shut off acid in the stomach, that acid can no longer kill any infectious bacteria in the gut. “[PPIs] change the type of bacteria in the gut,” explains Thota, “and may predispose you to pneumonia and other infections.”
Anyone taking PPIs would be wise to speak with a doctor before deciding to stop. If you don’t have a dangerous condition that PPIs should be treating, there are ways you can get yourself off the drugs, but be forewarned — you may be miserable in the short term.
There is a known rebound effect when people stop taking PPIs. That is, your stomach has spent so much time not making acid that once that mechanism turns back on, it goes into overdrive.
Dr. Christina Reimer, of the department of gastroenterology, Hvidovre University Hospital in Copenhagen, did research on this rebound effect and found that it takes at least two weeks (sometimes longer) for the stomach to get back to normal acid production.
“You can use antacids to treat rebound symptoms,” says Reimer.
In addition to antacids, Reimer suggests adjusting your diet to include small, non-fat meals.
Stern agrees. In Dropping Acid: The Reflux Diet Cookbook and Cure, a book he co-authored, he talks about eating a low-acid diet. That means cutting out citrus fruit, soda and tomato sauce, among other acidic foods.
He also advises avoiding food that relaxes the flap that covers your stomach and keeps acid out of your esophagus. Foods that do this include alcohol, chocolate and caffeinated beverages like coffee.
Coffee in and of itself is not as acidic as people believe. But, explains Stern, the neurological effect caffeine has on the body can increase reflux symptoms. Nicotine has the same effect.
Another tip: do not lie down or go to bed after you eat. Experts agree that staying upright three to four hours after a meal can reduce reflux symptoms.
Finally, you can try H2 blocker drugs, which are taken on an as-needed basis for indigestion. (Grams’ study also looked at the connection between H2 blockers and low magnesium and kidney disease and did not find one.) That’s the approach Alison Huck is taking these days — having switched to famotidine, also known as Pepcid.