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”
“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