What to Consider with Long-Term Use of Proton Pump Inhibitors & Options to Explore

Are you a patient on a proton pump inhibitor and ever wonder if there is another way? Especially if you question if it’s really helping?

I see patients on these for years, some times decades. Did you know they are technically meant for short term use? Overutilization is defined as using a PPI for longer than the FDA-recommended time period of 4 to 8 weeks. Physicians are allowed to use clinical discretion (as they should be able to) and weigh the pros and cons of staying on one, and the pros and cons of weaning off a proton pump inhibitor (PPI).

The reason I am writing about this is I often get looped in when a patient on a PPI gets referred to me, and I am to provide medical nutrition therapy which includes assessing and making nutrition related recommendations. Nutrition assessment includes reviewing medical history, biomarkers, and pharmaceuticals.

First of all, what is a PPI?

PPIs are a class of drug that reduces stomach acid, with the goal of reducing acid reflux or the street name: “heartburn.” These also are prescribed to prevent and treat ulcers in the stomach and small intestine. PPIs include lansoprazole (Prevacid), omeprazole (Prilosec), pantaprozole (Protonix), and rabeprazole (AcipHex), and esomeprazole (Nexium). PPIs can be wonderful for giving much needed relief, especially when a patient is miserable from their reflux syptoms.

Long term, what are the risks of taking PPI prescriptions according to Harvard Health:

• Pneumonia risk
• C. DIFF risk
• Fracture risk
• Iron deficiency risk
• Vitamin B12 deficiency risk
• Small intestional bacterial overgrowth risk

The above shows it’s really worth asking questions. What was all checked in the work up that came to the conclusion that starting on a PPI was the best intervention for reflux symptoms? Do we really known what led to reflux symptoms? Yes, sometimes there is the seemingly obvious root cause like a structural issue causing reflux or excess weight exacerbating the problem by pushing up and loosening the lower esophageal sphincter and acid comes up; but have other pontential underlying issues that can lead to acid reflux been ruled out?

Below are scenarios I’ve seen many times as a RD with 12 years of lived professional experience.

The acid reflux symptoms are not always from excess stomach acid. Being told to avoid tomatoes/caffeine/chocolate/greasy foods/eat early and take a PPI might surface level “fix” symptoms, but what if the root problem isn’t excess stomach acid? And the patient is on a medication (with risks) to reduce acid when excess acid is not the problem.

Other possible explanations for reflux symptoms (and these can all be intertwined and feed off each other):

• Low stomach acid
• Underlying H. pylori infection
• Underlying gut dysbiosis or intestinal bacterial overgrowth

Let me debrief the low stomach acid (aka Hypochlorhydria) thing as it sounds counterintuitive.

Low production of stomach acid can contribute to food not being properly broken down as stomach acid is a part of digestion and absorption. Inadequate break down of food can increase gas and pressure up on the lower esophageal sphincter that normally keeps the acid in the stomach (and not creeping up into the esophagus).

Sometimes, what’s really going on is improper digestion from low stomach acid. One common approach to reflux symptoms is throwing a PPI at it without digging deep. Yes, this can reduce symptoms (which I totally get wanting to make the patient feel better and prevent esophageal damage – on the same page with this) but there is a better solution: fixing the real problem. What’s wild is the PPI usage can continue to worsen the proper digestion and now we potentially have more issues to deal with like decreased nutrient absorption and maybe IBS type symptoms, and now another drug is added for that. (I’m painting a picture here. This doesn’t happen in all scenarios but don’t miss the boat, the big picture is thorough assessment and accurate diagnosis; this trickles down to dietitians as it dictates the medical nutrition therapy we provide. When our interventions don’t work or something doesn’t add up, we ask questions, make recommendations, and coordinate care with physicians).

Why does low stomach acid occur?

• Age: Hypochlorhydria is common as you get older. People over the age of 65 years are most likely to have low levels of hydrochloric acid.
• Stress: Chronic stress can decrease production of stomach acid.
• Vitamin deficiencies: Deficiency of zinc or B vitamins may also lead to low stomach acid.
• H. Pylori: is a bacteria that lives in the stomach and is common cause of gastric ulcers if overgrown; if overgrown and left untreated, it too can decrease stomach acid.
• Surgery: Surgeries of the stomach, such as gastric bypass surgery, can reduce production of stomach acid.
• Medications: Taking antacids or medications prescribed to treat ulcers and acid reflux, such as PPIs as stated above, for a long period of time may also lead to hypochlorhydria. If you take these medications and are concerned that you have symptoms of low stomach acid, speak with your doctor before making changes to your medications.

How is hypochlorhydria is addressed and cared for:

There are a variety of tests to check low stomach acid according to the Cleveland clinic. Once confirmed, addressing underlying causes, supplement with HCL (after H. Pylori is ruled out), drinking water between meals – not with meals, chewing food well and correcting nutrient deficiences are possible interventions according to the Cleveland Clinic.

Now onto the Scoop with H. Pylori:

A H. pylori infection occurs when H. pylori bacteria infect or “overgrow” in your stomach. H. pylori bacteria are usually passed from person to person through direct contact with saliva, vomit or stool. H. pylori may also be spread through contaminated food or water. H. pylori can also cause low stomach acid, which can contribute to decreased ability to break down food (and hence reflux symptoms) according to Mayo Clinic. If H. Pylori is overgrown, your healthcare team may recommend erradicting this, especially if symptomatic.

Gut Dysbiosis:

Gut dysbiosis means low levels of “good bacteria” and excessive colonisation of “bad bacteria” in the intestines. Some studies have shown that patients with bacterial overgrowth were more likely to have reflux symptoms.

There are medical management options and nutrition intervention options for the 3 other culprits of reflux lists above: Hypochlorhydria, H. Pylori, and Gut dysbiosis.

Truth be told, there can be multiple factors too. Big picture, it’s important to figure out what is causing what. Medical nutrition therapy performed by a RD works best when the correct culprit is identified. I ask questions, do a thorough review of medical history, perform a thorough nutrition assessment, look at the big health “picture,” and make recommendations to treating physicians if more data may be needed to best care for the patient. Patient advocacy means a lot to me, and getting the patient better is my top priority.

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