Call it the law of unintended consequences. Drug companies, doctors and druggists all thought that they were doing something wonderful for patients. After all, severe heartburn or GERD (gastroesophageal reflex disease) is common and distressing. When acid works its way up from the stomach into the esophagus it can cause burning and irritation. This can cause scarring of the sensitive tissues in the food tube and in some cases could lead to a condition called Barrett’s esophagus or precancerous cellular changes.
Suppressing acid formation in the stomach with a class of medications called proton pump inhibitors (PPIs) seemed like a great plan. Such drugs have become incredibly popular:
• Esomeprazole (Nexium)
• Lansoprazole (Prevacid)
• Omeprazole (Prilosec)
• Pantoprazole (Protonix)
• Rabeprazole (Aciphex)
You can now buy omeprazole (Prilosec) and lansoprazole (Prevacid) over the counter without medical supervision. Not surprisingly, these drugs are among the most popular pills for heartburn.
But there are a couple of problems. There is acid in the stomach for a reason. It was not a mistake of nature that most animals have highly concentrated acid in their stomachs. Acid is necessary to digest food and allow for absorption of certain key nutrients. Acid also kills lots of nasty germs that might get into our stomachs from food, water and other sources. Suppressing acid so effectively may increase our risk for certain infections. It also seems to increase the risk for a very serious and unanticipated complication: hip fracture!
An article just out from the BMJ (once known as the British Medical Journal) reveals that postmenopausal women who smoked (current or former smokers) and took a proton pump inhibitor for at least two years were at greater risk for hip fractures. Nearly 80,000 women from the Nurses’ Health Study were followed for roughly eight years. That represented over 500,000 person years of follow-up. There were about 900 hip fractures in this group of women. Compared with with women who never used PPIs the women who regularly relied on these acid suppressing drugs had a 35 percent greater risk of hip fracture. Smokers had a 50 percent increased risk for hip fracture.
In pharmacology we like to look at dose response curves and length of exposure to a drug to determine risk. In this case, the longer these women swallowed a powerful acid suppressing drug, the stronger the likelihood that they would experience a fracture.
This is not the first time research has suggested a link between acid suppressing drugs and hip fracture. When all the data are analyzed together the risk of hip fracture is increased by about 30 percent. Although the mechanism has not yet been nailed down, three possibilities have been considered. One, these drugs may interfere with calcium absorption, necessary for proper bone formation. Two, PPIs may directly interfere with the cells that help remodel bone and keep it strong. Three, by inhibiting acid formation, such medications increase the body’s production of gastrin, necessary for food digestion. Too much gastrin could negatively impact bone mineral density.
Based on the new finding from the Nurses’ Health Study and prior research, we now think that there is reason to be concerned about PPIs and and a link to hip fractures. The difficulty appears to disappear once such drugs have been discontinued for at least two years.
There is a problem, however. Stopping PPIs after several months of regular use can be difficult. Rebound hyperacidity (really bad heartburn) is a common complaint. You can read about strategies to get off PPIs by checking out this link and this link.
Of course we would suggest that anyone who considers stopping a PPI check with the prescribing physician first. Some people may have to stay on these drugs indefinitely because of Barrett’s esophagus.
We do have a number of non-drug suggestions for dealing with heartburn in our Guide to Digestive Disorders. You can also find a great deal of very practical information about reflux and heartburn in our book from National Geographic, The People’s Pharmacy Quick & Handy Home Remedies. You will learn about how to use almonds, bananas, broccoli, chewing gum, fennel, ginger, hot peppers, papaya, vinegar, yellow mustard, and a low-carb diet to control heartburn. You can also find our recipes for Persimmon Punch and Ginger Pickles to help control symptoms of reflux. All this is available in Quick & Handy Home Remedies.