Heartburn pain

There are new guidelines from the American Gastroenterological Association (Gastroenterology, March, 2017). They inform physicians that best practices require prescribing proton pump inhibitors (PPIs) to patients with Barrett’s esophagus for long periods of time. The goal of the treatment is to prevent this condition from turning into esophageal cancer. How good is the evidence?

GERD and Barrett’s Esophagus:

Heartburn that persists is both uncomfortable and worrisome. That’s because GERD (gastroesophageal reflux disease) can occasionally lead to abnormal cellular growth at the bottom of the esophagus. This is called Barrett’s esophagus.

Doctors worry about Barrett’s because it is a risk factor for esophageal cancer. They used to think that people with Barrett’s esophagus were 40 times more susceptible to this dangerous malignancy.

Research has shown, however, that this outcome is a lot less common than most health professionals think. About one person in 860 with Barrett’s will develop esophageal cancer every year (New England Journal of Medicine, Oct. 13, 2011).

That does not mean patients with this condition should ignore it. Far from it! When esophageal cancer occurs it is an extremely serious condition. Anything that could prevent Barrett’s from progressing to cancer would be beneficial.

PPIs vs. Esophageal Cancer:

Most physicians prescribe a proton pump inhibitor (PPI) for patients with Barrett’s esophagus. Guidelines from the American College of Gastroenterology recommend aggressive treatment with a PPI such as esomeprazole (Nexium), lansoprazole (Prevacid) or omeprazole (Prilosec).

The American Gastroenterological Association in its “AGA CLINICAL PRACTICE UPDATE: EXPERT REVIEWS” published in Gastroenterology, March, 2017, state:

“For patients with symptomatic GERD and Barrett’s, PPI therapy is highly effective for symptom relief and may potentially offer a chemopreventive effect, particularly since symptomatic reflux is a known risk factor for esophageal adenocarcinoma (EAC). In patients with Barrett’s esophagus who have no symptoms of GERD, PPIs are prescribed primarily to reduce the risk of progression to EAC.”

The experts for the AGA go on to state that:

“Epidemiologic studies generally support this practice, but there is currently no randomized data directly demonstrating that PPIs prevent progression of Barrett’s to EAC.”

A Different Perspective:

A study in PLOS One (Jan. 10, 2017) found a disappointing lack of evidence that these drugs prevent cancer of the esophagus. The article was titled:

“Proton Pump Inhibitors Do Not Reduce the Risk of Esophageal Adenocarcinoma in Patients with Barrett’s Esophagus: A Systematic Review and Meta-Analysis”

The Conclusions:

“In summary, no definitive protective effects against the development of EAC [esophageal adenocardinoma] and/or HGD [high-grade dysplasia] were seen for patients with BE [Barrett’s esophagus] with long-term PPI usage. Until and unless results of future studies can confirm such an association, PPI usage should be restricted to symptom control according to current guidelines. These findings indicate that for an unselected group of patients with BE, chemoprevention by use of PPIs to reduce progression should not be considered directly as routine care.”

These conclusions will surely be controversial, especially among gastroenterologists. PPIs have been the mainstay of reflux treatment for decades. They are perceived as highly effective and super safe.

PPI Side Effect Controversy:

In recent years, however, long-term side effects have come to light. They include kidney disease, pneumonia, intestinal infections, vitamin and mineral deficiencies, hip fractures and dementia.

Whenever we write about such complications, it makes some people nervous.

One reader complained:

“Every time I see an article about PPIs, it makes me sick! I have to be on Nexium because my acid reflux is awful. It caused a cough whenever I tried to eat. I wish you wouldn’t carp on the side effects so often. I’m sure everyone has gotten the message.”

Another reader wrote:

“I have Barrett’s esophagus and have been taking Dexilant [dexlansoprazole] for about five years now. I consider this a miracle drug. I had horrific heartburn and the Dexilant saved me.

“I went five years with no reflux whatsoever. But now I’m forgetting things. I don’t know if it’s just because I have so much on my mind, or if it’s from the medicine.

“My GI doctor warned me about dementia, but he said the risk of Barrett’s esophagus turning into esophageal cancer was of more concern than the possibility of dementia.”

Gastroenterologists Downplay Side Effects:

In its recent “Clinical Practice Update” the AGA experts state that:

“Despite the long list of potential adverse effects associated with PPI therapy, the quality of evidence underlying these associations is consistently low to very low. In addition, the magnitudes of absolute risk increase for individual patients are modest, particularly at once daily dosing.”

In other words, if there is a risk it is low.

That said, there is a growing recognition that PPIs have often been prescribed casually. That is why the AGA experts conclude:

“When PPIs are inappropriately prescribed, modest risks become important because there is no potential benefit.”

They go on to note that there are not specific recommendations to counteract PPI adverse effects.

What To Do?

No one should EVER stop taking a PPI without medical supervision. Rebound hyperacidity can make life miserable. Some people experience severe symptoms of heartburn for weeks or even months.

When people are seeking routine remedies for standard heartburn there are lots of options. Here is a video with a few of our favorites:

 

 

To learn more about heartburn and a variety of ways to ease symptoms, you may wish to review our Guide to Digestive Disorders. Anyone who would like a copy, please send $3 in check or money order with a long (no. 10) stamped (70 cents), self-addressed envelope:

  • Graedons’ People’s Pharmacy, No. G-3,
  • P. O. Box 52027, Durham
  • NC 27717-2027

It can also be downloaded for $2 from the website: www.peoplespharmacy.com

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  1. Donna
    Minnesota
    Reply

    Why don’t you include baking soda in your recommendations for heartburn? I find it to give me the fastest relief and no side affects. Doesn’t happen every day, but when it hits me at night, I don’t want to suffer any length of time.

  2. Sharon
    oregon
    Reply

    Regarding Peoples Pharmacy reporting side effects of PPI, I am ever grateful. I was prescribed the Rx after having an A/V malformation repaired in my stomach. I also have renal failure. As I had quit smoking I thought my symptoms of increased confusion and swollen legs were caused by that. I stopped the Prilosec and notified my Dr. He agreed… So kudus to the People’s Pharmacy.

  3. Lynn
    Silk Hope, NC
    Reply

    Is there any evidence that PPIs protects one from esophageal cancer in folks who have reflux but don’t have Barrett’s?

  4. Pat
    Superior Wis
    Reply

    Rather than treat with drugs, how about a midden fundalplication, a laparoscopic procedure to prevent acid from harming the esophagus? I had mine in 1996 and best thing I ever did.

  5. Dorothy
    Reply

    My daughter had serious GERD and Barrett’s esophagus. Had bad reactions from prescription drugs. She now uses aloe vera juice and other natural supplements. A year after starting this her doctor was amazed and delighted at her improvement.

  6. Judy
    Maryland
    Reply

    Please do not stop reporting side effects of PPIs. It was because of your reporting on a small study from Italy that I learned what was causing a horrible scaly patchy rash all over my husband’s body that was driving him crazy, and that his doctors, including a dermatologist, could not diagnose. It was a rare side effect of omeprazole.

    The rash disappeared in two weeks after he stopped taking it. Further, I started looking into other side effects and found that his muscle weakness and mental confusion were also related to the med. Just days before I read your article he had said he didn’t see the point of living if he had to live like this always. I have not seen the study reported anywhere else and I am eternally grateful to you.

  7. Gail
    Virginia
    Reply

    Is there a difference between GERD and mild heartburn? I take a calcium carbonate antacid about 5 or 6 times a week, usually at bedtime. Once when I mentioned that at the doctor’s office, the nurse practitioner entered GERD on my chart and tried to push a prescription. I don’t think it’s severe enough to warrant a powerful drug, but she was concerned about esophogeal cancer. Years later I asked the doctor to take GERD off my chart, but I think it has been added again. I don’t think it’s severe enough to have a diagnosis on my chart. What’s the clinical definition of GERD?

  8. Noah
    Chapel Hill, NC
    Reply

    I was diagnosed with GERD about thirty years ago and was prescribed Protonix initially, later Nexium and finally Prilosec. This dance of medications was based on availability of samples and cost of medication. Eventually I was on Prilosec daily, every day. I developed Barrets Esophagus anyway. I also developed a condition called Schatzki’s Ring. Not doing very well. I began before anyone really knew about the side effects.

    I was on PPIs, sometimes as many as two a day, for decades. About ten years ago I decided that the side effects were worth considering stopping the medication all together and I cut back from daily, to every other day, then four/three times a week to none. My GI guy was against it but he couldn’t have me come in every day to force a pill down my throat. I have been PPI free for five or six years at this point.

    I had no rebound effect and my GERD has disappeared. I do take Papaya Enzyme tablets (pretty cheap, pretty natural) but not even every day and mostly because i like the taste. I read here on the Peep’sFarmacy that it is is helpful with digestion.
    I may be luckier than most but I doubt it.

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