PPI’s – Risk vs. Reward
Proton Pump Inhibitors (PPIs) have been around for decades and are often praised for having little to no side effects in the short and long term. But a mounting body of research suggests that these pills, taken by millions, come with a variety of long-term risks and affects on health.
What exactly are PPIs? Proton Pump Inhibitors (PPIs) are a class of medications that work on the cells that line the stomach to reduce the production of acid. In Canada, these include: esomeprazole (Nexium), lansoprazole (Prevacid), omeprazole (Losec, Olex), pantoprazole sodium (Pantoloc), pantoprazole magnesium (Tecta), rabeprazole (Pariet), and dexlansoprazole (Dexilant).
PPIs are one of the top prescribed classes of drugs in Canada. Their popularity is due to the fact that they are usually well-tolerated, with minimal short-term side effects, and are used for a number of common issues, including:
- Acid reflux, heartburn and symptoms of gastro-esophageal reflux disease (GERD)
- Ulcers in the stomach and in part of the gut called the duodenum
- To prevent and treat ulcers associated with anti-inflammatory medications known as non-steroidal anti-inflammatories (NSAIDS)
- As part of a treatment regimen, along with antibiotics, to get rid of pylori
- Other rarer conditions, such as Zollinger-Ellison syndrome (ZES) and Barret’s esophagus
PPIs are viewed as a quick fix to symptoms that often interfere with people’s daily life. Many lifestyle factors can contribute to symptoms PPIs are used to treat,2 such as:
- What (triggers) and when you eat (e.g. before bed)
- Being overweight or obese
- Family history
- Cigarette smoking
- Alcohol consumption, and
It’s often easier to take a pill than to deal with what may be contributing to the symptoms in the first place. However, there’s emerging evidence that PPIs are overused—taken for too long, at too high of a dose, or for the wrong condition (e.g. for general stomach upset that’s not caused by GERD or ulcers).
PPIs have been associated with a variety of long-term risks and affects on health, including:
- Nutrient malabsorption and deficiency (particularly magnesium & vitamin b12, to a lesser degree calcium, folic acid, iron, and zinc)3
- Kidney disease 4
- Bone fractures 5
- Intestinal infections such as difficile 6
- An altered gut microbiome 7
- Risk of death 8
PPIs can be very useful to treat some serious conditions. Short term they can help your body heal from an ulcer and treat H. pylori. But they should be used at the lowest dose for the shortest duration.
It’s important to note that some people SHOULD continue to these medications long term, including those with ZES or Barret’s esophagus. Risks vs. benefits should be assessed for you by a qualified healthcare professional.
If you are interested in stopping your PPI medication there are a few things you should know. If you have been on a PPI, especially at a high dose or for a long period of time and try to stop it, you can get what is called ‘rebound reflux’. Because your stomach is used to suppressing acid production, when you stop the medication and your body starts to produce more, symptoms often return and they sometimes come back worse. Many people who try to stop “cold turkey” find their symptoms come back and must resort back to the medication.
To discontinue the medication, it is important to look at your gut health in a holistic way and to identify what was causing your symptoms in the first place. Working with a professional is the best way to identify contributing factors and resolve your symptoms.
At Wellth, we take a multi-pronged approach to gut health and getting you off of PPIs.
Our pharmacists are knowledgeable about “Deprescribing”. They will work with you and your healthcare team to create a plan tailored to you to slowly taper the drug, and identify other strategies and lifestyle modifications to help ease the transition off the medication.
Our holistic nutritionists can work with you to identify dietary triggers. They will help create a meal plan to ease you through the transition off the PPI and work with you to find an individualized plan that will keep the symptoms at bay, for good!
- Canadian Institute for Health Information. Prescribed Drug Spending in Canada, 2016: A Focus on Public Drug Programs https://secure.cihi.ca/free_products/Prescribed%20Drug%20Spending%20in%20Canada_2016_EN_web.pdf
- Locke GR et al. Risk Factors Associated with Symptoms of Gastroesophageal Reflux. Am J Med. 1999;106:642-649. http://www.amjmed.com/article/S0002-9343(99)00121-7/pdf
- Lam, R et al. Proton Pump Inhibitor and Histamine 2 Receptor Antagonist Use and Vitamin B12 Deficiency. JAMA 2013. 2013;310(22):2435-2442. http://jamanetwork.com/journals/jama/fullarticle/1788456
- Lazarus, B et al. Proton Pump Inhibitor Use and the Risk of Chronic Kidney Disease. JAMA Intern Med. 2016 Feb; 176(2):238-46. https://www.ncbi.nlm.nih.gov/pubmed/26752337
- Zhou B, et al. Proton-pump inhibitors and risk of fractures: an update meta-analysis. Osteoporosis Int. 2016 Jan;27(1):339-47. https://www.ncbi.nlm.nih.gov/pubmed/26752337
- Canadian Agency for Drugs and Technologies in Health (CADTH). Proton Pump Inhibitors (PPIs) and Clotridium difficile Infection (CDI): What does the evidence say? February 3, 2016. https://www.cadth.ca/proton-pump-inhibitors-ppis-and-clostridium-difficile-infection-cdi-what-does-evidence-say
- Imhann, F et al. Proton pump inhibitors affect the gut microbiome. Gut 2016;65:740-748. http://gut.bmj.com/content/65/5/740
- Xie Y, et al. Risk of death among users of Proton Pump Inhibitors: a longitudinal observational cohort study of United States veterans. BMJ Open 2017;7:e015735. http://bmjopen.bmj.com/content/7/6/e015735