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Problems with PPIs, Part 1: The down side of acid-blockers

Updated: Jan 31

If you’ve got GERD, acid reflux, heartburn, or indigestion, chances are you have tried prescription medicines to block stomach acid production. The drugs in this class, called proton pump inhibitors (PPIs), go by many names. You’ve likely heard of them as Losec, Nexium, Olex, Prevacid, Tecta, or Pantaloc. Their pharmaceutical names usually end with “prazole”, like omeprazole or pantoprazole. They are very commonly prescribed: currently, more than 50% of people over 65 use PPIs. They are generally considered to be safe, but were never intended for long-term use. Current guidelines say these drugs should only be used for 4-8 weeks! Yet we see people in our clinics who have been using these medicines for years, without anyone attending to the risks they may pose in the long run.

The US National Institutes of Health state that “Any drug that changes the normal physiological process of the body can have unintended consequences, and PPIs are no exception”

PPIs are inhibitors of proton pumps, targeting the proton pumps of parietal cells in the stomach that produce stomach acid. The idea is that by inhibiting this system, there will be less acid in the stomach, preventing the burning sensation of acid reflux. But there are several problems with this simplified theory:

  • Our stomachs make acid as a very important first step in digestion

  • Stomach acid kills harmful microbes in our food and water

  • Proton pumps are present in almost every cell of the body, so many organs can be affected, not just the stomach

Acid doesn’t just break foods down into smaller particles, it also sets your digestive system up for the correct acid levels all though the digestive process, like a domino effect. The pH in the stomach is often as low as 2. That’s really acidic! If you put a bit of bone into that acid it would dissolve in a day or two, that’s how strong it is meant to be. We still don’t fully understand how the stomach can hold that acid without digesting itself: another amazing example of how our bodies work. Reflux isn’t too much acid, it’s acid getting to where it shouldn’t be! It should be in your stomach and it shouldn’t be pushing up into your esophagus and burning the unprotected tissues there. You may be surprised to hear that in some people, the stomach juices can escape the stomach because the stomach isn’t acidic enough! That’s because the valve at the top of the stomach closes in response to acidity, and if there isn’t enough, it doesn’t close properly. The acid can then escape upwards. You may notice this at night, if you lie down too soon after dinner. One way to check if you don’t have enough stomach acid is to take 2 teaspoonfuls of apple cider vinegar in a little water just before a meal. This increases the stomach's acidity. If this helps, you are one of those who needs more acid, not less. PROBLEMS IN THE GUT PPIs Alter The Gut: The healthy microbes that should inhabit the gut are very sensitive to changes in pH. A less acidic pH in the stomach, followed by suboptimal pH all through the gut, affects the composition of good bacteria that are our first line of defense in a healthy digestive system. Stomach acid is also critical for killing any harmful pathogens in our food. Without sufficient stomach acid, bacteria like Clostridia, Salmonella, or Listeria, can make their way into our intestines. Studies have found significant increases in SIBO (small intestinal bacterial overgrowth) and C difficile (a really nasty gut infection) in PPI users. PPIs Impair Nutrient Absorption: Stomach acid is an essential early step to enable the absorption of many nutrients. PPI users have been shown to have increased risk of nutrient deficiencies, including vitamin B12, vitamin C, calcium, iron, and magnesium. These nutrients are important for the health of many organs including bones. Studies have shown an association between PPI use and bone fractures in the elderly. PPI Backlash: If people stop taking PPIs, they often experience a few days of increased acidity. When taking PPIs, your body senses that your stomach isn’t as acidic as it should be. It works harder to make more acid, which the PPIs then reduce, and so the teeter-totter goes back and forth. When you stop taking PPIs, there is often a lag before the body stops overworking to produce acid. So folks who stop their PPIs may mistake this rebound effect for having an underlying excess acid condition. If you need to deal with heartburn during this backlash, or while working to treat underlying digestive problems to get off your PPIs permanently, you can try:

  • Avoiding trigger foods. The worst trigger foods for GERD are caffeine, chocolate, carbonated beverages, tomato, citrus, spicy foods, peppermint, deep fried foods

  • Eating celery sticks or juice

  • Drinking alkaline vegetable broth made of celery, green beans and zucchini

  • Using herbal soothing demulcents, like slippery elm, marshmallow or licorice (the herbs, not the candies!)

  • If occasional acute relief is needed, baking soda in water can help. This should not be a regular solution because it is an antacid, and contains a lot of sodium.

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