older man with heartburn

Drugs that shut down acid production in the stomach are among the most popular pills in the pharmacy. The FDA considers them so safe that you can buy Prilosec (omeprazole) and Prevacid (lansoprazole) without a doctor’s prescription or supervision. Now add Nexium 24 HR (esomeprazole) to the list. It just recently became available over the counter and a huge advertising campaign is likely to make Nexium 24HR wildly successful.

PPIs are Big Business!

Doctors love these proton pump inhibitors (PPIs for short). They have been prescribed to millions of people for many years. There is a reason for the popularity. They work! Shutting down acid production in the stomach frequently cures ulcers and calms heartburn and acid reflux symptoms. What’s not to like about such benefits?

PPIs and Cancer

Oh yes, there’s one more thing. Doctors have been convinced that such drugs may prevent cancer of the esophagus or throat. A systematic review and meta-analysis of observational studies published in the journal Gut (online, Nov. 2013) concluded that the use of PPIs is associated with a reduced risk of cancer of the esophagus or nasty abnormal cellular growth in patients with something called Barrett’s esophagus.

Barrett’s Esophagus

Physician Norman Barrett first described the condition in 1950. He wrote about tissue abnormalities of the lower esophagus and related them to acid reflux. Colleagues proposed that the ulcers and abnormal cells of the lower esophagus be named after Dr. Barrett.

This condition is diagnosed through an upper endoscopy exam in which a flexible tube with a tiny camera is inserted into the esophagus. If there are are growths, ulcers and/or a dark pink salmon color to the tissue, the likelihood is that there is ongoing damage due to the reflux of irritating compounds from the stomach.

Precancerous cellular changes (dysplasia) are frequently apparent as well. There is an association between Barrett’s esophagus and a dangerous kind of esophageal cancer (adenocarcinoma). It’s no wonder, then, that when physicians detect Barrett’s esophagus that they try to reverse it.

We frequently hear from patients that their physician has prescribed a drug like omeprazole or lansoprazole for that very reason:

“My doctor told me you can not cure the Barrett’s esophagus, you can only control it with medications forever.” Izabela


“The doctor told me I should never stop taking daily omeprazole because I have Barrett’s and I would need to take them for the rest of my life. I will need to have an endoscopy every two years with biopsies until I reach the age of 75, because she said if I reach 75 then I won’t get cancer from GERD (gastroesophageal reflux disease). I am 41, and I would rather not keep taking omeprazole that long.” Lyndon


“I have Barrett’s Esophagus. My doctor told me I would have to take Prilosec for the rest of my life.” Barb


“My doctor wanted me to stay on Prevacid so I went back on it after a brutal self-weaning. I have slowly gotten off it again. Very slowly, including buying over-the-counter lesser dose and spacing it out. I do not have Barrett’s, though I did have scarring. I do have healed ulcers on the esophagus, which I healed with fresh cabbage juice after that first abandonment of Prevacid. I did not wean S L O W L Y enough.

“I told my doctor what I had read about the dangers of PPIs and he said ‘don’t read so much.'” D.S.


What if PPIs Don’t Prevent Cancer?

The common belief among health professionals is that if you suppress acid you can prevent the formation of abnormal cellular changes in the esophagus. This may in fact be true. But new research from Denmark (Alimentary Pharmacology and Therapeutics, May, 2014) raises disconcerting questions. The investigators point out that despite widespread use of powerful acid-suppressing drugs like proton pump inhibitors, the dangerous kind of esgophageal cancer (adenocarcinoma) continues to increase at an alarming rate. They also note that the research into the protective effects of PPIs on Barrett’s esophagus has produced conflicting and somewhat confusing results.

That is why they undertook a large epidemiological study of all Danish patients diagnosed with Barrett’s esophagus between 1995 and 2009. The Danes have a superb record keeping system that allows them to track virtually all patients in the country. What they found was shocking:

In this population-based study among patients with Barretts oesophagus, we were not able to prove a preventive effect from proton pump inhibitors, instead we found an increased risk of oesophageal adenocarcinoma and high-grade dysplasia [abnormal cells] related to long-term PPI therapy. Although methodological bias may limit the conclusions, this may in part lead to a re-evaluation of the treatment strategy for Barrett’s oesophagus.”

 What if PPIs Increase the Risk of Cancer?

This conclusion is both revolutionary and heretical and defies conventional wisdom. Not only are the researchers suggesting that PPIs don’t protect people who have Barrett’s esophagus, they imply that long-term use of such drugs might actually increase the risk of abnormal cells and even adenocarcinoma of the esophagus.

The Danish researchers explain their findings this way. They point out that when patients experience reflux of stomach contents into their esophagus, there’s more than acid in that juice. Bile helps digest fat. It can be quite irritating. They hypothesize that reducing acid in the stomach might modify bile chemistry and “PPI use may facilitate the formation of carcinogenic bile acids, explaining some of our findings.” They also point out that another stomach chemical called gastrin stimulates cellular growth. Gastrin is also likely to be part of the reflux mixture affecting the lower esophagus. They point out that acid-suppressing drugs have a powerful impact on gastrin levels in the stomach:

“The gastrin level may increase 5-10 fold during PPI therapy, and may have anti-apoptotic and proliferative effects that contribute to neoplasia [tumor growth]. This may increase the risk of gastrointestinal tumours.”

In fairness, this all remains speculative and there are conflicting data. At this time no firm conclusions can be drawn either way. That said, we do not disagree with the Danish researchers’ conclusions:

“Until the results from future studies can further elucidate the association, PPIs should be restricted to symptom control according to current guidelines. Hence, PPIs may not protect against malignant progression in BO [Barrett’s Oesophagus] patients and in selected high-risk patients, clinicians may consider adding or replacing long-term medical treatment with other modalities.”

We have actually been writing about these very issues for many years. You will find a much more detailed analysis of the pros and cons of acid-suppressing drugs in our book Best Choices From the People’s Pharmacy. You will read about PPIs and cancer, rebound hyperacidity when PPIs are stopped suddenly and some non-drug approaches to controlling symptoms of heartburn.

We must state emphatically that no one should ever stop medication without careful consultation with the prescribing physician. Discontinuing PPIs suddenly can lead to horrific heartburn. That is why it is crucial that people have a conversation about these complex issues with a knowledgeable health professional. You can do so by providing that person with a link to the article in Alimentary Pharmacology and Therapeutics so that he or she can download the full article from a medical library. You may also want to review our chapter on Heartburn in Best Choices From The People’s Pharmacy so that you will have some background information about this complicated topic.

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  1. Melanie T
    Reply

    Proton Pump Inhibitors nearly killed me! Please check the FDA website for their 5 page paper warning of Proton Pump inhibitors causing bones to leach out Magnesium, which will then cause the loss of Potassium. This was what landed me in the hospital on IV for 3 weeks. If you are on Nexium, Prilosec, Aciphex,etc. even now and then, be sure to have your doctor check your Magnesium and Potassium levels regularly.

  2. fbl
    Reply

    Tom S, you are entirely too trusting of medical professionals. Unfortunately they get brainwashed by the drug companies. Studies are done by the drug companies and data are removed that don’t prove what they want.
    Case in point: I fell and broke my leg last October. It broke just under the hip under the large part at the head of the femur. The Orthopoedic Dr. was totally amazed that it was a simple straight across break and didn’t affect the hip bone. He’d never seen it in someone my age. I’m 68. He expected the bone to be fractured down the length of the bone.
    Fortunately over 30 years ago a family Dr. encouraged me to take digestive enzymes (betaine HCL and enzymes). I have increased them over the years as needed. The other contributing factor is that I exercise. I have a Rebounder that I use daily and a treadmill.
    Most people my age need digestive enzymes. It will strengthen their bones and generally improve their health. Some younger folks need enzymes too. My son and my nephew did. I did a challenge test on them to find out. My son was a shrimp but finally started growing taller after starting the digestives (at age 35 he is 6’1″). My nephew’s behavior and ability to learn were dramatically affected. The nephew was living with us instead of being incarcerated in a psychiatric institution. Diet and assimilation of nutrients makes a HUGE difference.
    Do NOT blindly trust the medical profession! Do your own research and experimentation.

  3. Tom S.
    Reply

    It seems to me, that as long as PPI medications have been prescribed to patients in the U.S. with extensive research having been performed, both in clinical studies (double blind, etc.) and laboratory, I would find it difficult to undermine the integrity of both the FDA and very well trained physicians in the U.S. I understand and appreciate that there are studies performed abroad using extensive research, but until proven by the studies that have be performed in the U.S. I will continue to take PPI medication.

  4. EC
    Reply

    The main cause of acid reflux is LOW acid. The sphincter muscle at the top of the stomach doesn’t detect much acid, so it is a loose closing. Have the amount of acid in the stomach tested before using a PPI. I add acid at mealtime using Betaine. There are so many reasons to NOT use a PPI: lack of energy, B vitamin depletion, bones that are undermined, bacteria that can get past the acid barrier to cause disease, etc. At least test your stomach acid first to see if it is hurting because it is too low. When you add acid, the sphincter closes tightly, keeping the acid where it belongs, in the stomach. I wish I had known this when my Father suffered from this for years.

  5. Grace K. B.
    Reply

    I have just recently gotten off Prilosec. I did it by taking one every other day and adding a ginger cap. and a cayenne cap (I take cayenne for lots of things) daily. I also take a Aloe stomach Formula if I have reflux. It has worked wonders for me.

  6. Duane
    Reply

    My wife had Barrett’s along with some polyps. After taking Prilosec for 2 years, the Barrett’s completely disappeared and no more polyps. I guess there is always an outlier. My wife will continue to take Prilosec.

  7. fbl
    Reply

    Yes, one should never take it right before a meal. One needs stomach acid to digest and absorb nutrients from one’s food.
    If you often have an upset tummy you might want to try some ginger. Either in a tea, capsules or candied. I got through the nausea of chemo and radiation thanks to candied ginger. I shake off as much of the sugar as possible before using the container.

  8. MD
    Reply

    Are there any side effects from using baking soda?
    People’s Pharmacy response: Baking soda contains quite a lot of sodium (it is sodium bicarbonate). Taking too much or too often could upset mineral balance in the body. Swelling or unusual sudden weight gain signal a problem.

  9. JAS
    Reply

    What about balancing the body’s overall and individual acidity/alkaline levels — (depending on the unique needs of each of the organs, tissues, cells, etc., all the different components of the body, plus the body as one unit) — through diet? The holistic theory is that the continuous acid/alkaline levels of the body should be “in balance between acid & alkaline, for each body component… that is, for individual cells, for blood, for tissues, plus the body overall, which needless to say, gets very complicated. All the new age and holistic theories mention that acid/alkaline levels have a strong effect on cellular division. Wasn’t there recent news about how researchers have gotten cells to divide while bathing them in an acid solution? And isn’t cancer about cells dividing uncontrollably?
    Can The People’s Pharmacy comment on this and clarify/clear up this convoluted/complicated debate on acidity and alkalinity levels of the body as a whole, in individual cells, in tissues, in blood, etc., as it impacts Barretts and other esophageal health issues? Is there already a podcast or written summary about this on People’s?

  10. CAW
    Reply

    To Kathy F. Here’s what I did: Get a lower dose of the over the counter match to what you are taking and use it for a week then take every other day for a week then go to every three days for a week and go gradually till off. Talk to your pharmacist and ask for a very lose dose you can take of an OTC when you have wine or tomatoes only at night. One that only lasts say 9 hours. While doing this gradual wean load up on gum and chew it continuously along with tums. Also small sips of water if you feel the acid rise in your throat. Wear loose clothes and try not to bend over but squat. I did this and it worked. Take two regular tums right before I know I am going to eat the foods that set me off -wine, anything spicy, tomatoes as precaution. Don’t eat within three hours of bed time. Do raise the head of your bed. Good luck

  11. LT
    Reply

    I can’t speak to the cancer issues, but I do know that PPIs prevent absorption of the B vitamins. The result it progressively worse memory resembling dementia. I became so forgetful, I couldn’t perform properly on my mail route. After research, and weaning myself off Prilosec, my memory recovered to normal (with the aid of massive doses of B-complex and B-12).

  12. AB
    Reply

    My dr. prescribed Prilosec for heartburn which I took for about a year. I had blood work done after discontinuing Prilosec because I was feeling fatigued and was found to have very low magnesium levels. I took magnesium supplements per my dr and got my levels back to normal. This is one side effect of taking acid suppressing drugs. I think its worth sharing my experience. People should be aware of the list of side effects. I don’t have heartburn issues anymore. They weren’t that bad to begin with.

  13. KAS
    Reply

    This is super helpful, thanks! Husband has Barrett’s and I want to stay on top of what the best treatment options are. He’s only been on the PPI for a short time, but we surely don’t want him on it for the rest of his life.
    Thank you for being on the forefront of health discoveries and best practices!

  14. fbl
    Reply

    SC, I agree with your comments. I have had several friends whom I’ve helped get off the PPIs. It is a slow process but they succeeded and are now healthier for it.
    Folks with gastro problems often need more digestives NOT less. By improving their digestion their bone health improved and they became healthier.
    I was fortunate over 30 years go when I went to a new Dr. He was a very old guy and experienced. He is the one who told me to start taking digestives. “Keep trying until you find one that works for your body” is what he told me. It didn’t take long and I’ve found that every few years I have to do a self test again to make sure I’m at the right amount of Betaine HCL and the other enzymes.

  15. Bill S.
    Reply

    A number of years ago I was diagnosed with GERD and put on Nexium. I too was told I would have to take the drug for life. Over the years of taking this medicine I developed other stomach and digestive problems. I began asking my doctors if proton pump inhibitors could be contributing to these problems and was told that this was a tradeoff I had to accept. I was successful in getting them to agree to reduce the amount I was taking, but not to completely stopping.
    Finally, I decided to go it alone and slowly weaned myself off the medicine. I did it very slowly, over a period of about 6 weeks and had few problems which I countered with over the counter products. I feel much better and got a positive reaction from my doctor at my recent physical.
    I have had this experience with other medications, and my conclusion is that once on a medication, doctors are reluctant to take a patient off, perhaps due to possible legal ramifications. I am finding more and more that doctors are reluctant to give me their opinion on treatment options and that’s too bad for both the medical profession and the patient.

  16. sp
    Reply

    I have had GI problems all my life. As an adult, doctors prescribed PPIs, etc., for “IBS”. When my bone density test showed bone loss, I decided against these meds for good. The best relief for GI distress is to drink a small glass of buttermilk. It usually does the trick. Doesn’t do it every time and I occasionally take an antiacid, but the buttermilk is far and away the best remedy.

  17. SC
    Reply

    I’ve been reading recently that LOW stomach acid can produce heartburn and that most people need more – not less – acid. The acid helps the food digest faster, get out of the stomach faster, and stops heartburn.
    This seems counter-intuitive to what the doctors say we need. What do you think?

  18. Kathy F.
    Reply

    Ten or so years ago I was prescribed Nexium by Gastro MD due to acid reflux. I took it for about 2 years with no issues. The acid reflux did resolve.
    Now, ten years later, after endoscopy was performed due to stomach/reflux issues, I started Nexium again. I couldn’t take 40 mg due to joint pain that I believe the Nexium caused. I have been taking 20 mg. for past 3 months. I notice that if I forget to take one day, my stomach/reflux issues are bad. I do not want to continue taking for extended period.
    What are my options? Does the Persimmon tea really work? Where can I purchase this? I am thinking of going to a Chinese medicine person. Any thoughts?
    PEOPLE’S PHARMACY RESPONSE:
    Please discuss the new research from Denmark with your doctor. As we said, this is not a do-it-yourself project. You need monitoring and supervision.
    Stopping Nexium or any PPI cold turkey is not a good idea. Rebound hyperacidity can cause severe symptoms for weeks or even months.
    Search this website for more details on the withdrawal process if your doctor approves such a strategy. Here is a link:
    http://www.peoplespharmacy.com/2013/10/03/stopping-nexium-esomeprazole-suddenly-can-cause-severe-heartburn/

  19. CAW
    Reply

    Many Doctors just push pills rather than taking the time to discuss how to control heartburn with diet, weight loss etc. Mine never even mentioned that there is surgery for weak hiatal hernias. Just said you need to take this (very expensive) pill the rest of your life. I was suffering from fatigue while on it due to not absorbing my B vitamins, magnesium and several others. Weaned myself off painfully over six months and now just a tum before bed works.

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