Richard Knox did a splendid job on NPR discussing rebound hyperacidity brought on by the sudden discontinuation of acid-suppressing heartburn drugs like Nexium (esomeprazole), Prilosec (omeprazole) and Prevacid (lansoprazole). When such medications are stopped, they frequently cause the very symptoms (acid reflux) that they were originally supposed to eliminate.
Many gastroenterologists have a hard time believing this, since they prescribe huge quantities of PPIs (proton pump inhibitors). Until recently, it was easier to say that the patient’s symptoms just returned and that the drugs could not be responsible for worsening symptoms.
This is reminiscent of the days when drugs like Valium (diazepam), Librium (chlordiazepoxide) and Xanax (alprazolam) were so popular. When patients complained of severe anxiety and insomnia on stopping such drugs many physicians replied that such symptoms were merely the return of the underlying psychological problems. We now know, however, that withdrawal from benzodiazepines (Valium-like drugs) is common and requires gradual tapering over weeks or months.
No doctor wants to cause harm. But it is surprising how many medications can cause unexpected side effects. When such drugs are first introduced there is a tremendous marketing effort by the pharmaceutical firms touting the benefits of their new pills. Just think back to those “Purple Pill” commercials for Nexium! Rarely do companies tell patients or physicians that there may be a dark side to their hugely successful medications.
To read more about this fascinating topic and to listen to Joe on NPR, just click on the link below:

http://www.npr.org/templates/story/story.php?storyId=112564382

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  1. Nancy
    Reply

    I have been taking omeprazole and did not take it with me to CA for my two weeks travel. One day my whole chest was on fire. I saw a local pharmacist and he said it was because I stopped the omeprazole and nothing surpressed the acid reflux. He told me to never take omeprazole again that it was a very bad drug and said not to take any type of those medications.
    He gave me something else OTC and it really helped but can’t remember the name. I am now taking DGL Licorice – 1-2 chewable tablets 20 min. before a meal. If I forget, I chew it afterwards. These can be obtained at the health food store. Just started this regimen and hopefully it will help with the numbness in my feet and hands.

  2. Bf
    Reply

    Does anyone know why the alt would be elevated after taking prevacid? I too have this experience after taking Prevacid only 4 months. I was very sick and switched to Zantac which my dr is unhappy with. The nausea and mental effects were horrid, and I didn’t have any reflux symptoms before starting it. Also lost weight and having a problem putting it back on. I am convinced it interfered with the assimilation of thyroid drug, as my hair starting falling out.

  3. CAH
    Reply

    JBB, The info I referred to was what I now see in your post one or two back–thank you, I’ll check them out. I can’t tell you how much I appreciate your suggestions, and thoughts, as well as those of other posters. It very much makes sense to very gradually cut down on the Prilosec, and that is my plan. I’m hoping the old bod can adjust with a minimum of misery.
    Whether or not the bed-tilting is really helpful, I can’t say. After reading that a lot of night time poor sleep is related to reflux issues, it made sense to do everything possible to avoid it, as sleep in senior years I’m finding a challenge anyhow.
    We try to eat our “main” meal mid afternoon, with only a snack at the later hour of “usual” dinner. As I mentioned before, I don’t over eat– and minimize those foods which tend to aggravate one’s GI tract–chocolate, spicy foods, etc. I don’t drink or smoke. My food vice is fat–I love butter–but will cut down on that, as that is a good suggestion, too. Don’t wear tight clothes (looks awful on old women anyhow!). So, I think I am doing what I can to win this battle.
    Thank you again.

  4. JBB
    Reply

    CAH,
    Are you asking for the links I sent or someone else’s? Unclear on that. Did you see the story but not the study? Not sure how you’re going about the decreasing of dosage but I would go very slowly. For example, maybe take 3/4 of what you normally take for 2 weeks or even a month until your body is used to it and then consider decreasing to 1/2 and so on.
    Since you’ve been on PPI’s for 10 years, your body really has some adjusting to do! And, unlike things like Zantac, I don’t think PPI’s are set up to work instantly as it takes awhile for them to build up in your system and also awhile for them to get out of your system. So, that may be why you’re fine for 3 days when trying to decrease the dose. I’m not a doc or anything and I don’t know how exactly you’ve gone about it but those would be my thoughts.
    From what docs have told me, weight loss can definitely help. But, if you aren’t able to accomplish that, at least doing simple things like not wearing belts and/or avoiding tight clothing can help, too. And, try to make sure not to eat on the run and/or while stressed. A relaxed digestive system is a happy digestive system. :) Also watch your fat intake as that’s bad for reflux, too. I never tried the bed tilting thing myself but they do say that helps. Glad to hear that works for you.
    Good luck!

  5. CAH
    Reply

    Appreciate all the information and suggestions. I do have my bed on a tilt, and that seems to help somewhat. I was interested in the info referred to by the previous poster, but didn’t see the articles mentioned. Could you repost with references?
    I have my almonds ready for action, and will buy some apples, stock up on TUMS and prepare myself for a bit of an ordeal. I never overeat, as that turns into a nightmare of misery even WITH a PPI! Also, am overweight, and losing some would be helpful in this quest.
    Fascinating the study that found reflux in perfectly normal, non GERD patients, after taking PPI drugs. That should give a message right there to docs who prescribe it to at least use some caution.
    There seems to be some controversy over whether to stop “cold turkey” or gradually decrease the dose. I’ve tried the decreasing dose theory, and so far, I can get up to every third day–and then symptoms resurface.

  6. JBB
    Reply

    CAH,
    Just thought I’d take this opportunity to pass on all that I’ve learned thus far about acid reflux, PPI’s and whatnot. I haven’t taken the time to reread this entire link so if I restate something I apologize.
    Anyway, the way I see it, the reason there can be a rebound effect with PPI’s is that your body can realize that not enough acid is being produced. If this happens, then your body can respond by simply producing more acid producing cells. You don’t notice this happening while you’re on the PPI’s because (whether you have too many acid producing cells or not) the PPI is usually still able to shut off the acid production.
    But, when you try to go off of the PPI you suddenly have many more cells producing acid than you did before and so you end up with 10 times the normal amount of acid than you should have (or something along those lines).
    The goal would then be to get through this situation and to hope that your body would normalize eventually on its own (the faster the better). I don’t have any great answers for this process per se. I’ve read some different things. Some people claim that PPI’s either work or don’t work and so aren’t dose dependent, suggesting that you can either be on them or off of them and that the amount you take shouldn’t matter. But, I would be inclined to believe that it would be worth it to try to do a very slow taper in dosage and see if you have some success.
    Also, Ranitidine (Zantac) is another type of acid inhibitor that works in a different way (H2 blocker) which might be able to at least take the edge off of stopping your PPI. Gaviscon is another option as the way it works is it actually forms a film (something to do with some seaweed) that helps to close your lower esophageal sphincter and so then keeps whatever excess acid you may have down. Some people claim it really helps so that might be worth a try. At the very least, it’s probably harmless.
    The other thing that I have learned is that acid production can be very dependent on your diet. When you eat protein you produce more acid. When you eat carbs you tend to produce less acid. It’s just the way it goes. So, you may want to take note of how you feel when you eat meat versus mashed potatoes and start experimenting with using this as a way to temporarily control your symptoms.
    Obviously, you will ultimately want to eat a wide variety of things but you might be able to control things for a short time in this way. Other foods that may help to decrease acid production are apples and almonds so you may want to snack on those for awhile as well.
    Exercise is also important to help to normalize things and I think I believe reading something about some studies that were done that found that walking can literally reduce your acid production. So, maybe some simple walks, especially after meals might help.
    Lastly, I would like to also point out that sometimes the reason people have acid reflux is actually because they do not have enough acid. What happens in that situation is that the acid that you do have may have a tendency to travel up your esophagus and cause reflux. From what I understand is that this happens because the lower esophageal sphincter needs enough acid in order to stimulate it to close. The “cure” for this type of reflux would be a high protein diet which would encourage more acid production and keep that acid down in your stomach. You may also want to avoid foods that relax this sphincter such as chocolate, tomatoes, and peppermint.
    Apple cider vinegar regularly also helps this as it adds to the acidity in your stomach.
    Here is a link to one of the more recent studies about the PPI Rebound Effect: http://download.journals.elsevierhealth.com/pdfs/journals/0016-5085/PIIS0016508509005228.pdf
    Here is the NPR article explaining it (again, I apologize if you’ve already seen this): http://www.npr.org/templates/story/story.php?storyId=112564382
    I had one other study that about this, too, but can’t find it at the moment. Hope some of that helps! Good luck!

  7. JBB
    Reply

    bacs, I have finally been diagnosed with something that makes a lot more sense. I have POTS or Postural Orthostatic Tachycardia Syndrome. I had to go to Mayo Clinic to finally get diagnosed. Anyway, the gist of it is that my body is under stress when I stand most likely due to my vessels being too loose because of hypermobility. So, my body was literally in fight/flight mode when I stood.
    I won’t go into depth about the POTS but it does come with digestion issues at times (about 1 in 3 cases or so). Besides, I would assume that if I was in fight/flight mode a lot then my digestion would be messed up because one has to be relaxed in order to digestion their food.
    Because of the POTS I have had to go back on PPI’s. I actually currently take both Aciphex and Zantac. I tried the Aciphex because the Prilosec seemed to make my dizziness issues with my POTS worse. Things seem to be going OK, within reason. It is just basically like I have IBS. I never had ANY digestion issues before so that has been a difficult adjustment for me. I have been avoiding lots of carbs and some sugars as those seem to trigger my digestion issues.
    A local gastroenterologist has confirmed that a diet like the South Beach Diet (which is heavier on the protein than carbs) usually works for people with IBS. So, I am hoping that as my POTS improves that I will eventually be able to wean myself off of the Aciphex and Zantac. The Zantac actually seems to work the best for me right now. But, both are important to keep things just kind of settled down down there.
    I am going to post some info on some of the studies that I found on the rebound effect of PPI’s and what else I have learned along the way in a reply to CAH below. So, please check that if you’re interested. I agree that acid reflux needs to be investigated a lot more per case in general. It appears that many docs these days simply through PPI’s at people rather than figuring out what’s really going on.

  8. Rocket Scientist
    Reply

    Gradually reduce the amount of Prilosec over a long period, 2 or 3 months, is my best advice. What apparently happens is that the stomach’s ability to produce acid for digestion has become stronger as it has fought the Prilosec. When the Prilosec is gone, the stomach doesn’t instantly ramp back production. Apparently, it takes a while for the stomach to believe the battle no longer needs to be fought.
    My best advice is sleep on a slant. I use a wedge that puts my upper body at a 30-degree angle.

  9. CAH
    Reply

    I am fascinated by this discussion, as I have been trying to get off the cussed Prilosec for a couple of years–every time I do, after a few days, I am so miserable that I weaken and start it again. Whether it is “really” GERD or rebound, of course, is impossible to know. I just came from talking to my local pharmacist–who, interestingly, had never heard of a rebound effect from PPI’S! He has no helpful advice about how to stop it.
    I’m going to try some of the suggestions that I have read on this site, steel myself for a miserable time, and see if once and for all–I can’t stop it. I am concerned about the studies that show several ill effects from long-term use–and mine has been very long term indeed–well over 10 years. Every time I discuss it with my doc, he just says it won’t hurt me and keep taking it. I’m not sure he believes there is really a rebound, or knows about it either.
    Will be delighted to see any other helpful suggestions posted, or other folks experiences.

  10. bacs
    Reply

    JBB – I, too, was prescribed a PPI with no symptoms of acid reflux. I have 3 very small duodenal ulcers probably developed 3 years ago due to high use of Motrin. I’ve had no symptoms whatsoever. But since starting Prilosec a week ago, I’ve had constant heartburn (burning in the pit of my stomach) and sometimes a feeling of reflux deep in my throat. I’ve decided, starting today, that I’m going to stop the Prilosec. Hopefully I won’t have any rebound acid reflux after just this short period of use. I thought all along that it is ridiculous to stop acid production when there is no evidence of hyperacidity.

  11. bacs
    Reply

    Endoscopy found 3 small duodenal ulcers… asymptomatic. Not caused by H. Pylori. Dr. put me on Prilosec to heal the ulcers. Said I would have to be on it for at least 3 months… wanted me to take 40 mg/day but only took 20 (mornings). Been on them a week… have had constant heartburn every day with added reflux feeling a couple of days since taking it! Never had this before the Prilosec!!! Haven’t taken an antacid in years. Have decided to stop them as of today and see if the heartburn goes away.

  12. JBB
    Reply

    I was prescribed omeprazole a few weeks ago for a case of Vocal Chord Dysfunction. I had never had any heartburn/GERD issues in the past. If so, they were extremely mild. I hadn’t been taking anything prior to being diagnosed with the Vocal Chord Dysfunction (VCD). The VCD was, however, probably caused by some silent acid reflux due to the fact that I had recently herniated a disc in my neck and had spent a considerable amount of time (weeks) lying flat as that was the only thing that seemed to help.
    Well, the very “wham bam thank you ma’am” ENT who waltzed in and diagnosed me with VCD gave me a prescription for omeprazole just in case my situation was caused by reflux (although he seemed to believe a lot of it was anxiety, according to his dictation, which doesn’t make the least bit of sense in my case at all, but that’s not the point here).
    Anyway, I take the med for 2 weeks because it’s a prescription and I think I need it. During this time, I actually start tasting my acid reflux. I hadn’t had that problem before. Then, about a week after I stop taking it I start getting weird symptoms: feeling weak and as if I’m going to pass out; I start shaking like I have the chills and urinating frequently after I drink a Gatorade. I have nausea, diarrhea, then start getting the worst heartburn I’ve ever experienced (I seriously didn’t know it could be that bad).
    I’m not hungry or able to eat much of anything, my stomach feels bloated and paralyzed, etc. Heck, I even hiccuped up undigested bits of carrot along with stomach acid! I go to the ER and the Urgent Care. Both doctors think I’m nuts and I have anxiety. One even listens to my stomach and reports, “Well, your stomach does sound in distress. Have you eaten anything today?” As if I’m some anorexic or something and causing my own problems! Sheesh!
    Anyway, once I found this info (thank you, thank you, thank you) I haven’t been so worried about what the heck is going on. But, let me tell you, it has not been a fun ride. I went cold turkey and it’s been 3 weeks about since I’ve been off of it already and it’s still really bad. I have to take Zantac regularly. I tried to stop it today and the same stuff happened (started urinating frequently, not hungry, etc).
    It’s pretty ridiculous, especially since I’ve already been babying my stomach for so long. I lost 7 pounds in a week and have only been able to ever so slowly add in regular foods. I’ve been drinking protein type diabetes shakes and other “power packed” and low sugar foods as I’ve noticed my stomach can’t handle too much glucose or food in general at once as the food just sits in there and nothing is digested. At the same time, though, I need nutrition so the food I do eat, I make sure has lots of nutrients.
    I had almost no digestive tract issues before this so, again, it’s pretty ridiculous. Other than my herniated disc (which is a whole different story) I am a healthy young woman. I couldn’t imagine going through this withdrawal stuff if you’re a person who already normally has issues with stomach acid or a hiatal hernia! I still can’t believe it!

  13. Rocket Scientist
    Reply

    Re: Surgery to build a backup hiatal valve.
    The results from the January 2010 surgery to build a back-up hiatal valve using my stomach wall (fundoplication) were perfect. I have been sleeping flat, eating late, etc. and experiencing no reflux.
    Last Saturday night (4 months post-op), the reflux returned. Every night since has been like pre-surgery. Something came “undone.”
    I won’t let them fix it as it’s a lot of money, time and risk for something I now don’t trust to last. I am so sad about it.

  14. Rocket Scientist
    Reply

    In January, I had the surgery (fundoplication) that built a valve out of my stomach wall. It was done completely down the throat with no external incisions. I spent one night in the hospital, never felt any pain, and have a tight valve. There’s no acid reflux, and I have to burp occasionally. Before, air could not accumulate in my stomach. I stayed on a liquid/slippery diet for three weeks as instructed. Since then, I have eaten a regular diet. I have had no problems swallowing food.

  15. ebm
    Reply

    E.L. you buy dried persimmon pieces or slices and simmer 3-4 slices in quart of water
    for 30 min. I strain it and simmer again with fresh water (to rinse some more good out
    of it), just a couple of minutes. One of the readers takes a shot glass AM and PM. My
    friend forgets or takes aloe vera juice (got it a Publix grocery store). Persimmon also
    tastes good as a dried fruit or fresh (only season is Oct/Nov.) You can go online to
    order it at $10 or $12/lb or buy at Whole foods for $7.50 for 4oz. Asian food stores keep it in
    freezer/fridge section. This info came from People’s Pharmacy site and blogs.
    Good luck.

  16. chill
    Reply

    Okay, arthritis is helped by adding needed Vitamin D, acid reflux could be helped by adequate amounts of D, cancer could be caused by inadequate D and ALL of these diseases are caused by inflammation! There is surely a connection and I am adding more D to my supplements. (bladder cancer survivor, GERD, arthritis in many joints.)

  17. AJS
    Reply

    Just read the comments regarding low iron and vitamin D levels in regard to PPI use.
    I too had low ferritin levels and below normal vit D while using a PPI. The doctors response was to send me for Venofer infusions, which worked for a while, and vitamin D orally, which didn’t. In fact, vitamin D tablets LOWERED the level.
    I have not had these deficiency problems since stopping the medication and now just make sure I get some sunshine a few times a week (in my southern area 10-15 min 2-3 times a week is sufficient.

  18. E.L
    Reply

    I started taking aciphex 8 years ago. I went for a routine exam and my blood work came back showing anemia. I was then given many endoscopys and colonoscopys to determine if there was bleeding; the results were negative. I told the doctor that I believed the aciphex was causing me to have the anemia reading because in order for iron to be adequately absorbed it requires an acidic condition.
    He said in theory I was correct, But he said many people are on acephex without problems; But I said everyone was not alike. I also had numbing in my toes. I continued with the drug for 2 more years. Then my insurance didn’t cover Acephex, so the Doctor switched me to Nexium.
    The problem still continued although I learned not to complain; thinking everyone goes through this. Again, the Insurance did not want to continue the Nexium drug, My Doctor prescribed Zantac. I went off Nexium and started Zantac.
    I have had stomach cramps and indigestion since going on it; but no acid reflux. It has been about a week and my stomach feels upset. I am taking the Zantac every day sometimes every other day. I have a hiatel hernia.My bloodwork also shows Low levels of Vitamin D. Is the Zantac just as bad? Will I have to go through stomach upset for months?

  19. D. S.
    Reply

    My 8-year old daughter had the Nissen surgery as a baby, GERD complications from prematurity. She is the size of a 5 to 6 year old. GI doctor put her in Prevacid for two months, now she has symptoms of chest/stomach pain, which she didn’t have before. would a calcium citrate chewable, maybe half tablet be ok for a 42-pound kid? Plus the Persimmon tea, which I am having trouble finding, a tea spoon at night?

  20. AJS
    Reply

    Followed the “Best choices…” advice on stopping PPI med, (in my case Prevacid,) and it worked. When I had any discomfort or pain, took a CHEWABLE calcium citrate tablet with just enough water to swallow, and at other times especially after meals chewed some sugarless gum. After two months of doing this I am much better and only need minimal amt of calcium. This regimen also possibly SAVED MY LIFE!
    In the beginning, 2003, Prevacid was a life-saver and the damage from reflux mostly healed (some residual damage), and continued med at reduced dosage and frequency till 2009 when I started to become sick. Lab tests showed high ALT and AST (liver enzymes) in May. By July the levels had doubled again and I was extremely ill, couldn’t eat, losing weight rapidly and had a swollen abdomen. Ultrasound and cancer test negative, but on my own I suspected Prevacid and stopped taking it. This month ALT and AST normal and am feeling well and gaining back lost weight.
    The literature from the drug mfr does say that these meds are for short term use and have not been tested for long term. But the doctors I have asked about this had all said it was ok to keep taking it and not a word about how to stop.
    Thanks again to People’s Pharmacy.

  21. alxzba
    Reply

    One word of caution with the surgery to repair the hiatal valve. Be sure to have the test done that measures the strength of the esophageal peristaltic action — if you are having problems in swallowing, it may be that this action is simply not strong enough to force food down the esophagus (it does not ‘free fall’ to the stomach!).
    If the hiatal valve is tightened, this will cause food to not be allowed to pass into the stomach and will back up in the esophagus. Have had this done and it proved that I could not have the valve repaired for the mentioned reasons. Small bites, well chewed, and minimum reflux med (famotidine 10 mg prior to meals has worked for me), plus T of maalox at bedtime has helped tremendously.

  22. Robomatic
    Reply

    I was initially prescribed protonex, and after a couple of months on it I stopped using it and went Over The Counter with Prilosec which I used for about five years. My experience is that I could lower the dosage but then I needed to take it very regularly. If I got off of the regularity I would experience very sharp reflux recurrence pains, and not only did it take about a day for a re-initiation of prilosec to calm the acid, I would also experience regular chest pains which were quite alarming because they did not feel like acid pains.
    It is my understanding that Proton Pump Inhibitors either turn off the acid producing cells or not, you can’t take fewer tablets and expect that to work, because they either are working (no acid) or they fall below a threshhold and the acid is full on. Therefore you don’t ‘wean’ yourself off with a reduced dose, you substitute another drug or face the fact that you’ll go off cold turkey, which is what I did.
    Ultimately I read that if one followed up the last meal of the day with apples or almonds one would experience a sharp reduction in acid reflux pains. So a week ago I quit prilosec cold turkey and have been eating more apples. I am now back to standard reflux pains and I intend to deal with them by some other means than a proton pump inhibitor in future.

  23. Rocket Scientist
    Reply

    I read an article that warned of the 2 months of agony I would be in if I stopped the Prilosec so I was prepared. I argued with the gastroenterologist who put me on it and wish I had stood my ground. Even though I gradually reduced the dosage, I still had the two bad months.
    My problem is that there is always a one centimeter opening between my esophagus and stomach. I am a mechanical engineer. This is a mechanical problem. There is nothing wrong with my stomach acid. I have read that reducing stomach acid reduces the body’s absorption of critical vitamins and can lead to brain function deterioration among other scary things.
    I am planning to have the hiatal valve fixed when insurance agrees to pay for the non-invasive surgery – which is cheaper… Meanwhile I eat early and sleep on a slant. I hope my esophagus is not too torn up. I have developed a problem of pills getting stuck in my throat so know there is some deterioration.

  24. Noah V.
    Reply

    I have been taking these drugs continuously for about seven years. At first Protonix, then Nexium and for the past five years Prilosec. I switched only because I was getting samples until five years ago and when my doctor ran out I could get the Prilosec OTC. For the past year and a half I have been taking two pills, one in the morning and one at night. One had ceased being adequate.
    I have been literally afraid of how my body would respond if I stopped. About two months ago my wife and I began feeling concerned that all this Prilosec could be affecting my bone-calcium. I am 63 years old. I began cutting back by taking a half in the evenings for two weeks and a whole in the morning. Then I took the half every other evening for two weeks. Two weeks ago I switched to the whole at night and that was it. I have missed as many as two days in a row with no ill effects.
    I am currently being fairly regular about the one at night. Remembering five or six nights a week. I have had no particular ill effects from this significant cut back. But maybe I’ll go buy some Broccoli in the morning….

  25. K.O.
    Reply

    I have a peptic ulcer and have been on Protonix since 2005. Recently, my insurance company stopped covering it and I have been very sick since then. Apples do help, because of the pectin, and I carry a bottle of liquid antacid around with me. I have heard that a mixture of apple cider vinegar and honey helps but I haven’t tried it yet.

  26. SRB
    Reply

    I have been on Nexium, Prevacid, and Protonix due to severe acid reflux and have permanent damage to my esophagus resulting in Nissen Fundoplication surgery. I have been on Protonix since 11/05 but due to the economy and the high cost of this medication I stopped taking it.
    Is Protonix included in this study? I have been ill since going off of this product but I also have Fibromyalgia and have been diagnosed with Crohn’s Disease and have been treated several times for H-Pilory. My diet consists of a LOT of soda crackers.
    Could discontinuation of Protonix be adding to my gastrointestinal problems?

  27. Darold S.: CSEP, PE
    Reply

    Good Morning,
    I just heard a report on NPR (KERA) about the problems people are having with stopping using drugs like prilosec. Joe had an input on the program.
    We have found that when we have heartburn – which is seldom – fresh fruit, in particular apple, immediately relieves the problem.
    Grapes, orange, grapefruit, and many other things work well also.
    Have you heard from others as well?
    Regards,

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