Questions and Answers about Medications and GERD
What are the differences between the proton-pump inhibitors? Do they all have the same side effect profile? If I experience side effects from one, will I experience the same effects if I try another?
Proton pump inhibitors (PPIs) are the most commonly prescribed class of medication for the treatment of heartburn and acid-related disorders. They work by blocking the site of acid production in the parietal cell of the stomach. Because there are millions of parietal cells that are constantly reproducing, complete inhibition of stomach acid production is virtually impossible. This probably explains the tremendous safety of these medications.
There are a number of PPIs available in the United States and more are in development. The medications are structurally and chemically similar. There are relatively few comparisons of these drugs with each other. All the medications heal esophagitis in 90-94% of patients. There are no significant differences in overall healing and symptom improvement rates between the medications. Omeprazole (Prilosec) and lansoprazole (Prevacid) have been available the longest and consequently are the most familiar to physicians and patients. While the newer medications, rabeprazole (Aciphex) and pantoprazole (Protonix) have data to suggest better suppression of stomach acid compared to omeprazole, there is no proof that the differences are clinically important. Rabeprazole and pantoprazole are smaller and may be better for patients who have problems swallowing capsules. Pantoprazole is marketed as being cheaper, and may be better for patients paying for their own medications. Esomeprazole (Nexium), a new and very potent PPI, was approved by the U.S. Food and Drug Administration (FDA) in 2001. Zegerid is a combination of omeprazole and sodium bicarbonate. Dexlansoprazole (Dexilant) was FDA approved in 2009. Omeprazole and lansoprazole are now available over-the-counter.
The PPIs have been shown to be safe. Most of the information that we have on side effects come from studies where a PPI is compared to a placebo. The most common side effects are headache, abdominal pain, bloating, diarrhea and nausea. They occur in 1-2% of patients given PPIs. Interestingly, the incidence of these "side effects" is the same as when patients take the placebo. It is hard to compare side effect profiles between the medications, but there is no reason to believe that there are significant differences.
There is no scientific data to guide physicians on how to deal with the relatively few patients that have side effects from one of the PPIs. However, nearly all physicians have had the experience of switching from one PPI to another successfully. If a patient is having side effects from a PPI, they will not necessarily develop the same side effects if they switch to another PPI. The patient should be encouraged to discuss this option with their physician. The only exception may be in the extremely rare instance of severe allergic reactions.
I am an older adult on multiple medications. I have developed problems with reflux. What are the common medications that may affect the tone of the lower esophageal sphincter (LES)? What can I take to correct the problem?
The medications most likely to cause clinical problems are the calcium channel blockers and theophyllines. Calcium channel blockers are commonly used for high blood pressure and angina. Theophyllines are oral medications, commonly used for asthma and breathing difficulty. These types of medications weaken the lower esophageal sphincter, making it easier for stomach acid to reflux into the esophagus. The list of medications that may worsen gastroesophageal reflux also includes most sedatives and narcotic pain relievers. Many of these concerns are more theoretical than scientifically proven. Additionally, it is not likely that these medications will cause reflux in an otherwise healthy person.
If prescription medications are causing reflux to worsen, then there are two options. First, try to switch the offending medication to something else. There are many types of medications available to treat high blood pressure. The inhalers for asthma and other breathing problems probably cause less reflux than the oral theophyllines. Second, if the offending medication cannot be stopped, better treatment for the reflux would be in order. For example either increasing the dose of the current medication or switching to a more powerful drug may be the only alternative.
People who suffer from reflux should be aware of another pill-related problem. If a medication were to become lodged in the esophagus, it may cause injury to the lining. This may lead to ulcers and narrowing of the esophagus. Medications most likely to do this are certain antibiotics (particularly tetracycline), potassium supplements, quinidine (a medication for heart palpitations), and alendronate (Fosomax). All non-steroidal anti-inflammatory agents, even those over the counter, can do this as well. A good rule of thumb is to be careful with any pain medication. Other than acetaminophen, patients taking medications for pain should do two things. First, take a full glass of water with these medications to wash them down. Second, do not lie down for 30-60 minutes after taking these pills. Taking these precautions helps one to more safely take these medications and help avoid pill-induced injury to the esophagus.
I have serious heartburn several times during the day and night. I have found that a teaspoonful of baking soda in a little water gives me fast relief. Is this harmful? I have been taking it for several months now.
This is a fairly common a scenario. While I am happy that the baking soda works for you, there are a couple of problems with this approach. First of all, you have discomfort before realizing that you need to take something. There are excellent treatments available that could virtually eliminate the heartburn from occurring in the first place. Secondly, the sodium content of baking soda is not healthy, particularly for people with heart problems, high blood pressure, or kidney disease. There are other antacids that will work just as well with fewer consequences.
I look at three different situations where patients require relief from heartburn. First, there are many people who suffer from frequent heartburn. Second, there are people who have infrequent heartburn, but it is predictable before a large or a late meal, for example. Third, nearly everyone has episodes of heartburn and wants immediate relief.
If you are feeling heartburn 2–3 times per week, you are actually having acid reflux many times per day. In this situation, you should be on prescription medication to prevent the heartburn from happening. There are a number of proton pump inhibitors (PPIs). These medications greatly decrease, but do not eliminate, the production of stomach acid. It is the stomach acid that is causing the symptoms. They will greatly decrease, if not eliminate heartburn before it happens. These five medicines have similar efficacy, and very few side effects. They work best if they can be taken before a meal.
The H2 receptor blockers modestly decrease stomach acid production. They are inexpensive, so some managed care organizations often insist that their patients take them instead of the more expensive and more effective PPIs. However, if the H2 blockers don't work well, patients can usually get a PPI if needed.
If you have infrequent, but predictable heartburn, taking an over the counter preparation will work fine. The H2 receptor blockers are also available over the counter in a smaller dose. They will prevent or decrease problems if taken before a meal that usually causes heartburn. Some PPIs are now available over the counter for short term use. Although a PPI is more powerful than the H2 blockers, it is hard to know if it will be more effective for this type of discomfort.
If you are having heartburn and want immediate relief, over the counter antacids (e.g., Maalox, Mylanta, Gaviscon, etc) are still the best. They act quickly to neutralize the acid and provide prompt relief. The other over the counter medications will not work faster. It is fine to take these medications in combination. For example if you have heartburn while taking PPI, you may take an antacid to relieve it.
One more point, if you are having heartburn on a regular basis, you should let your physician know. Many people having heartburn two or more times per week have more serious medical problems that may require medical attention.
I suffered for years from pain and heartburn until I was diagnosed with gastroesophageal reflux disease (GERD) two years ago. The problem was finally brought under control when my doctor prescribed a proton pump inhibitor. Now I just read an article on the Internet about a report in a medical journal (JAMA, December 27 2006) saying that people who take this medicine for over a year have a high risk of hip fracture. My mother had osteoporosis. How concerned should I be about this?
Many patients were alarmed recently by news reports of a 44% increase in the risk of a hip fracture if they are taking a proton pump inhibitor (PPI). The currently available PPIs include omeprazole (Prilosec, Prilosec OTC, Zegerid), lansoprazole (Prevacid), pantoprazole (Protonix), rabeprazole (Aciphex) and esomeprazole (Nexium). This is the latest in a series of articles that have questioned the safety of these powerful, widely used medications. Worldwide, PPIs have been available for over 20 years. In the 1980’s there were concerns that, by profoundly decreasing stomach acid production, they might lead to other health problems such as serious infections, poor absorption of vitamins and minerals, even gastrointestinal cancers. However, by the mid-1990s, based largely on anecdotal experience, it was becoming clear that PPIs were remarkably safe. Formal studies looking at the use of PPIs in hundreds of patients showed virtually no long term side effects. As a result, new PPIs were developed, PPIs became generic and ultimately available over the counter without a prescription. This was a great advance in our ability to treat the millions of patients worldwide that have acid-peptic diseases.
In the last few years, researchers have been able to evaluate the side effects and complications of medications by using large databases of millions of patients. A recent report in the Journal of the American Medical Association looked at the medical records of over 9 million people in the United Kingdom. They were able to identify over 13,000 people with a hip fracture and compare them to over 135,000 people who did not have a hip fracture. They found that using a PPI for over 1 year increased the risk of a hip fracture by 44%. They also found that the risk increased further if the patients were taking the PPI a longer period of time, or at higher doses. This is probably due to impaired calcium absorption when there is less acid in the stomach. Now, it must be mentioned that the patients with hip fractures in this study were much more likely to be a cigarette smoker, be thin, be a diabetic, be alcoholic, have had a stroke, had dementia or had previous bone fractures. Studies like this talk about the risk per patient-year of follow up. For example if one follows 100 patients for 10 years, that is 1,000 patient-years of follow-up. This study suggests that the risk of a hip fracture that is specifically related to PPI use is about 2 per 1,000 patient-years.
There have been other reports over the past couple of years about the possible risk of pneumonia and infections of the colon with a bacterium called clostridium difficile in patients taking PPIs. Again, these articles looked at the medical records of hundreds of thousands of patients and found a small increased risk in patients using PPIs. Additionally, like the hip fracture study, other medical illness such as diabetes, heart and lung disease were also important risk factors.
The Canadian Task Force for Preventative Health Care recently published recommendations for the prevention of osteoporosis in women. It mentioned major risk factors such as advanced age, family history of osteoporosis, early menopause, propensity to fall and minor risk factors such as being thin, smoking, excess alcohol or caffeine intake. We may learn that long term PPI use will be considered a minor risk factor. If you need to take a PPI, you should talk with your doctor about your risk of osteoporosis. If you have other risk factors, you may need a bone density test. You may simply need to take exercise more or take calcium supplements. You may need to take one of the many excellent medicines for osteoporosis.
It has probably been wishful thinking that the long-term use of PPIs was perfectly safe. Like most medications, there are side-effects and complications. Fortunately the overall risk of long-term PPI use still seems to be relatively small. Common sense tells that if you don’t need to take a PPI, you should stop it. There any many people taking PPIs that could get away with using a less powerful medication. However, most people who need to take a PPI should be able to safely continue to take it without the fear of serious complications.