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.
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?
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.
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.
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 Barrett‘s 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.”
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.