Do I have a disease? Or is my body trying to tell me something.
Acid reflux symptoms affect over 25% of the US population. Reflux, or acid indigestion, is also called gastroesophageal reflux disease, or GERD for short. This is a disease where contents that made it to the stomach rise back up, or reflux, into the esophagus. When we swallow food or take a drink it travels from the throat, down the esophagus, and into the stomach. This is typically a one-way street as things should not travel backwards and reflux into the esophagus. However, this can happen and is the source of great irritation and concern for many Americans. Chronic heartburn is the most common symptom of GERD. Less common symptoms include hoarseness, difficulty swallowing, coughing, indigestion, and bad breath. If left untreated, GERD may lead to ulcers, bleeding, inflammation, and significant damage to the esophagus. If the damage to the esophagus goes on long enough it can lead to the development of esophageal cancer. The stomach is protected from the acid by a mucus lining, but the esophagus does not have any protection from the strong acid present in the stomach. When this makes it backwards into the esophagus it can cause a great deal of problems.
Several medications are used to treat GERD. The most prescribed, the most powerful, and most dangerous medications to treat GERD are called Proton Pump Inhibitors, or PPIs. When they are used properly and for the correct amount of time, they are safe. However, millions of Americans take them much longer than they should, which leads to many possible side effects including osteoporosis, vitamin and mineral deficiencies, increased risk of intestinal infection, kidney disease, and increased risk of pneumonia.
Omeprazole is the 10th most prescribed medication in the United States. This is not the entire class of medications, known as Proton Pump Inhibitors (PPI) but the single medication alone.4 About 100 million PPI prescriptions are dispensed annually.1 Many of these are not prescribed for good reasons. One study showed that between 25% and 70% of patients taking a PPI do not have an appropriate indication.2 Many people are prescribed a PPI for short term use and then continue it without realizing they should have stopped it after only a few weeks or less. They are often prescribed when someone is admitted to the hospital for stomach ulcer protection. The stress of being very sick and admitted to the hospital can lead to stress ulcers in the stomach and GI tract. Doctors often start patients on a PPI while admitted in order to help prevent any problems with ulcers during the hospital stay. They usually have enough other things to worry about. However, when the patient is discharged home the medication is usually continued by mistake. This happens all the time. The medication is on the patient’s medication list, and they are ordered to continue it after leaving the hospital even if they never had any symptoms of GERD or ulcers before going to the hospital.
Not only are they given more often than is appropriate, these medications can be extremely difficult to stop. You must be very careful when trying to stop PPI medication. It can be extremely difficult to stop taking, even for someone who had no symptoms of GERD before they began taking the medication. There is a rebound effect when someone stops taking a PPI.3 They are very powerful and stop the acid from being pumped into the stomach. However, the brain and body are still telling the acid producing cells of the stomach that we need acid to help digest food. So, every time we eat the body sends signals to produce acid to help digest the meal, but if you are taking a PPI the process is held up right before it is released into the stomach. That leaves a dam of acid built up inside the cells ready to be released almost immediately. Then, as soon as you miss a dose or stop taking the PPI all that acid gets released and causes excruciated symptoms of GERD and acid reflux. That is why many people continue taking them, even when they do not really need them. The rebound of acid secretion fools you into thinking that you really have terrible GERD and that you clearly need the PPI to control it. However, many times that is not the case provided you can taper down off the PPI slowly and carefully.
So, what are the problems with chronic Proton Pump Inhibitor (PPIs) use?
- Irritable bowel syndrome (usually with diarrhea)
- Malabsorption (decreased B12, calcium, magnesium, and iron absorption)
- Increased risk of osteoporosis and bone fracture
- Yeast overgrowth (like Candida)
- Increased risk for small intestine bacterial overgrowth (SIBO)
- Infection – Clostridium difficile-associated disease, Pneumonia
- Dementia
- Chronic Kidney Disease
Taking Proton Pump Inhibitors longer than intended can increase your risk of many illnesses. Studies have shown increased risk of irritable bowel syndrome, problems absorbing vitamins and minerals, changes to the healthy balance of bacteria and yeast in the digestive tract, infections, problems with memory, and even kidney disease.
So, if esophageal reflux can cause serious medical problems, but the best treatments for it (PPIs) cause other significant medical problems how do we treat and control esophageal reflux?
The American Journal of Gastroenterology promoted lifestyle modifications that include:
- Weight loss for patients with GERD who are overweight and had a recent weight gain
- Elevation of the head of the bed (if nighttime symptoms present);
- Elimination of dietary triggers
- Fatty foods, caffeine, chocolate, spicy food, food with high fat content, carbonated beverages, and peppermint
- Avoiding tight fitting garments to prevent increase in gastric pressure
- Promote salivation through oral lozenges or chewing gum to neutralize refluxed acid
- Avoidance of tobacco and alcohol and
- Abdominal breathing exercise to strengthen the barrier of the lower esophageal sphincter.10
There are other prescription medications without the long term problems caused by PPIs. Famotidine (Pepcid) is a histamine blocker that can decrease acid production in the stomach and treat acid reflux without the problems that come from PPI use. Licorice5 is a longstanding traditional remedy to improve digestion, promote a healthy stomach lining, and bacterial balance. Slippery elm bark is another traditional remedy that may help with GERD. It is rich in mucilage, which helps maintain normal inflammatory balance. Slippery elm (Ulmus fulva) has been used as an herbal remedy in North America for centuries. Native Americans used slippery elm in healing salves for wounds, boils, ulcers, burns, and skin inflammation. It was also taken orally to relieve coughs, sore throats, diarrhea, and stomach problems. Slippery elm contains mucilage, a substance that becomes a slick gel when mixed with water. It coats and soothes the mouth, throat, stomach, and intestines. It also contains antioxidants that help relieve inflammatory bowel conditions. Slippery elm causes reflux stimulation of nerve endings in the gastrointestinal tract leading to increased mucus secretion. The increased mucus production may protect the gastrointestinal tract against ulcers and excess acidity.6
Our recommendation for treatment of acid reflux (GERD) is to start with the all-natural remedies that contain Licorice, Aloe, Slippery Elm Bark, and/or Marshmallow Root. You can then add Famotidine (Pepcid) if needed. It is fine to take a PPI, such as omeprazole, for a few weeks but I would definitely not advise someone to take them for more than 2-3 months due to serious detrimental health conditions.
1. U.S. Food and Drug Administration. FDA Drug Safety Communication: Low magnesium levels can be associated with long-term use of Proton Pump Inhibitor drugs (PPIs). http://www.fda.gov/Drugs/DrugSafety/ucm245011.htm.
2. Forgacs I. Overprescribing proton pump inhibitors. BMJ. 2008;336(7634):2–3.
3. Niklasson A, Lindström L, Simrén M, Lindberg G, Björnsson E. Dyspeptic symptom development after discontinuation of a proton pump inhibitor: a double-blind placebo-controlled trial. Am J Gastroenterol. 2010;105(7):1531–1537.
4. https://dfr.oregon.gov/drugtransparency/data/pages/top-25-most-prescribed.aspx
5. https://www.nccih.nih.gov/health/licorice-root
6. https://icahealth.com/wp-content/uploads/Ehrlich_Slippery-Elm.pdf
7. Wang Y, Wintzell V, Ludvigsson JF, Svanström H, Pasternak B. Association Between Proton Pump Inhibitor Use and Risk of Fracture in Children. JAMA Pediatr. 2020;174(6):543–551.
8. Thong BKS, Ima-Nirwana S, Chin KY. Proton Pump Inhibitors and Fracture Risk: A Review of Current Evidence and Mechanisms Involved. Int J Environ Res Public Health. 2019 May 5;16(9):1571.
9. Lehault WB, Hughes DM. Review of the Long-Term Effects of Proton Pump Inhibitors. Fed Pract. 2017 Feb;34(2):19-23
10.Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol. 2013;108(3):308–328.