The reason for this blog post is to bring awareness to a common scenario we see on a daily basis, long term proton pump inhibitor use. I see multiple new patients come in the office who list either Prilosec or Nexium as a daily medication. When I go over their medications and ask about these PPI’s the patient typically tells me they have been taking them for “awhile” and buy them over the counter so they won’t get heartburn. When I ask them how long “awhile” is, I generally hear anywhere from six months to a few years.
As providers we know that PPI’s are an effective medication class in controlling heartburn. Ideally, a PPI course should be no more than 8-12 weeks. McQuaid (2017) explains that over 80% of patients will have a relapse of their GERD symptoms within 3 months after completing a successful PPI course. So, what is the average patient going to do when their heartburn comes back after 3 months? They are going to go buy “heartburn” medication at the store and keep taking it. There isn’t anything wrong with that as long as the patient is educated about the risks that can occur with long term use of PPI’s and that they are educated about other solutions of how to resolve GERD symptoms. The patient has the right to make an educated decision for themselves.
The majority of patients I see aren’t aware of the potential risks of long-term PPI use. When I educate patients that they are at a higher risk of having iron, magnesium, vitamin B12 and calcium deficiencies because the PPI they’ve been taking for years is doing its job, they seem surprised. I explain to them that the PPI suppresses acid secretion in the gut which will affect the absorption of these important vitamins and minerals and with low acidity levels the gut lining will be altered. Now, let’s think about what happens if a person is deficient in these vitamins and minerals and has an altered gut lining. Anemia, fatigue, osteoporosis, loss of appetite, increased risk for GI infections (C. difficile) and weakness are just a few things that come to mind. If the tables were turned and I were the patient, I would want to know these things and do whatever it took so I wouldn’t have to take a PPI for the rest of my life. It is our duty to make our patients aware of this.
Let’s review some basic nonpharmacologic modifications that should be made for patients with GERD symptoms:
- Eating smaller meals
- Eliminating acidic foods (citrus, tomatoes, coffee, spicy/fatty, chocolate, peppermint, alcohol)
- Avoid lying down 3 hours after meals
- Elevate the head of the bed with a 6-inch block or piece of foam if having night time symptoms (McQuaid, 2017)
Every patient we see for GERD should be educated about these basic foundation treatments. We all know that one of the biggest predisposing factors to GERD is weight gain and being overweight or obese. A study done by Singh et al. (2013) showed that a 5-10% body weight reduction in women and ≥10% body weight reduction in men over a six-month time period, through diet, physical activity and behavior modification, resulted in the majority of participants having a reduction or complete resolution of GERD symptoms.
If you think about it, losing 5-10% body weight in someone who is overweight or even obese really isn’t that much. That’s a simple, realistic goal to set for patients in a six-month time frame. The patient has to want to lose the weight though. If the patient is “fat and happy,” as I’ve heard some say, and content with controlling their heartburn with PPI’s for the rest of their life knowing the potential risks of long-term PPI use, then that is their decision. But at least we have done our part to educate the patient about the risks associated with long term PPI use and educated them regarding ways to completely resolve their symptoms through lifestyle changes.
McQuaid, K. (2017). Gastrointestinal disorders. In Papadakis, M. A., & McPhee, S. J. (Eds.). (2017). Current medical diagnosis and treatment (pp. 578-673) (56th ed.). McGraw Hill Education.
Singh, M., Lee, J., Gupta, N., Gaddam, S., Smith, B. K., Wani, S. B., . . . Sharma, P. (2013). Weight loss can lead to resolution of gastroesophageal reflux disease symptoms: A prospective intervention trial. Obesity (Silver Spring, Md.), 21(2), 284-290. doi:10.1002/oby.20279