If I enter a room filled with one hundred random people, and ask a simple question —“How many of you have acid reflux?” — how many people would raise their hands?
About 40 to 45, and that’s not even counting those too shy to admit it.
Gastroesophageal reflux disease (GERD) is probably the most prevalent disorder of the digestive system currently in the United States. Therefore, the use of stomach acid reducers is also very common.
Proton pump inhibitors (PPI) are some of the most effective agents that reduce the production of gastric acid, thereby bringing relief to millions every day.
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Their discovery is perhaps one of the most ground-breaking advances in medicine in recent times. It has dramatically reduced the number of patients that suffer on a daily basis with acid reflux and stomach ulcers, and it prevents surgeries that would otherwise be done on such patients.
And the most remarkable thing about these medications — few to no side effects for most people. Headaches and diarrhea are the most commonly seen side effects, and only in a small minority of patients. This is why PPIs are now available over the counter, to be used without a prescription. According to some estimates, 3 to 5 percent of the entire adult U.S. population has used the medication at some point.
But just as we thought we are sailing toward the glorious sunset, a couple of research studies have disturbed the waters a bit. New research shows that taking PPIs is not as risk-free as we initially thought.
PPI use and the risk of kidney disease
A recently published study published in JAMA Internal Medicine — one of the most highly respected and widely read journals in medicine — reports that PPI use is associated with kidney damage.
The researchers used information from U.S. Department of Veterans Affairs databases to follow about 10,000 patients for about 14 years. Some of these patients were taking PPIs or some other alternative acid-reducing medications. All the patients had normal kidney function at baseline.
Over 14 years, those in the PPI group were about 50 perent more likely to develop chronic kidney disease than patients not taking them. The results were then replicated using an even larger set of about 250,000 patients, followed over six years.
PPI use and the risk of dementia
Another study recently published in JAMA Neurology, another highly respected medical journal, reports that PPI use is associated with dementia.
The researchers followed about 70,000 patients, all above the age of 75 and all free of dementia at baseline, for about seven years. The study, conducted in Germany, found that the patients receiving regular PPI medication had about a 40 percent increased risk of getting dementia compared with the patients not receiving PPI medication.
So are these risks real?
In the world of medicine, there is a certain hierarchy of the strength or the “trueness” of medical evidence. It’s graded from level 1 to 4, with level 1 being the best/strongest form of medical evidence.
These studies on PPIs don’t reach level 1, but they certainly are strong level 2 evidence. They are composed of large numbers of patients, well-conducted and are published in journals that usually require very high level of quality and scrutiny before accepting any study for publication so I think these studies and risks certainly cannot be ignored.
That being said, a VERY important thing to realize is this — these studies show that the PPI-taking population is 40 to 50 percent more likely than the control group to be affected by these adverse effects.
It DOES NOT mean that 40 to 50 percent of patients taking PPIs will get these side effects. The actual proportion of patients taking PPIs that get these side effects is a much smaller number, less than 15 percent.
Additionally, the dementia risks are evaluated only in patients above the age of 75, which as an age group is more prone to getting dementia. The risks in a younger population are not known at this time.
So what do I do if I take these medications regularly?
Well, that’s a tough question. If you take these medications for acid reflux disease, and you take them fairly regularly, it’s important to have a discussion with your doctor about the pros and cons of taking these medications.
Reflux disease is a common problem, and its treatment relies on not just medications, but also certain changes in lifestyle — not eating late at night and propping up your head while you sleep are important as is avoiding alcohol, carbonated beverages, caffeine, chocolate, mints, high-fat foods and high-spice foods.
If you are overweight, then losing a few pounds will also help. Of course, that’s easier said than done, but a sincere effort can help provide a lot of symptom relief by itself.
There is another class of stomach-acid reducers called H2 receptor blockers that don’t have these risks. Examples of this class are cimetidine (Tagamet), Famotidine (Pepcid), etc. They are not as efficacious as PPIs, but do provide acceptable symptom control in many patients.
Lastly, there are surgical and endoscopic procedures also available for the treatment of reflux. Most of these treatments require some evaluation to select the appropriate patients for them, and carry with them some risks as any other invasive procedure would.
Last but not least, like every decision in medicine, a careful risk vs. benefit analysis should be done before deciding on the best course of treatment for a particular patient.
We hope that in the near future, Level 1 evidence will emerge on this issue, which would definitely be a big deal for this entire class of medications and its manufacturers and users.
Until then, keep calm and talk to your doctor!
Dr. Akshay Gupta is a gastroenterologist at Idaho Gastroenterology Associates (idahogastro.com) in Boise. Gupta did his internal-medicine residency at the University of Pittsburgh and completed a gastroenterology and hepatology fellowship at the University of Michigan. Gupta received additional training in interventional endoscopy, ERCP and endoscopic ultrasound at the Moffitt Cancer Center in Tampa, Fla.