Heartburn, Indigestion & Protein Pump Inhibitors

I have seen multiple adult patients with intractable heartburn, reflux, indigestion and chest pressure all related to food and digestive enzymes kicking back up the esophagus from the stomach through a lax group of muscles known as the lower esophageal sphincter.  All these patients receive a fiber optic upper endoscopy (EGD) at some point and are observed and biopsied to eliminate the possibility of ulcers, cancer, gastric polyps, esophageal cancer, potential esophageal cancer and Helicobacter Pylori bacteria as the cause.

They are all treated with weight control suggestions, avoiding a host of foods, most of which are quite healthy from a cardiovascular standpoint plus limits on alcohol, elimination of tobacco and other indulgences of adults. We ask these patients to wear loose clothing at the waistline, avoid reclining for three hours after eating and take a host of medicines including proton pump inhibitors (PPI) such as Nexium, Protonix, Prilosec.  Drugs like Tagamet, Zantac (H2 Receptor Blockers), Tums, Rolaids are far less effective.

In recent years, numerous articles have appeared in medical journals stating that protein pump inhibitors, when taken regularly, can predispose to increased and early death, pneumonia and dementia.  A large review article from a prominent GI group in Boston, and published in the New England Journal of Medicine, tried to eloquently refute these claims but the doubt about long term safety lingers buoyed by numerous lay periodicals and online internet sites sensationalizing the down sides of these medicines.

To allay the patients fears, doctors and patients work together to try and stop the PPIs and substitute the older standbys like Tagamet and Zantac but they just don’t provide the symptom relief that the PPI’s do. Patient’s face the dilemma of taking the medicine that works best and incurring the potential risks or suffering.

In a recent edition of the journal Gastroenterology, Paul Moayyedi, MB ChB, PhD from McMaster University in Canada followed 17,000 patients for three years with half the group taking PPI’s. Those taking a PPI (Protonix) for three years had no more illness or adverse effects than those taking a placebo.  L. Cohen, MD, a reviewer at Mount Sinai School of Medicine in NY, concluded that the study provided strong evidence of the safety of PPIs for patients taking the drug for three consecutive years.

The controversy will continue. I am sure next week someone will produce data revealing some additional horrible consequences of taking these medications to relieve heartburn. It will ultimately come down to individual decisions about quality of life versus potential risks because the lifestyle changes necessary to control this problem are difficult for human beings to sustain over a long period of time.

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pH Testing For GERD May Save Money

HeartburnHeartburn and dyspepsia are common conditions exacerbated by being overweight, eating too much, eating certain types of foods (red sauces, berries, alcohol, fatty foods, caffeinated beverages, chocolate) reclining after eating, wearing constrictive clothing at the belt line and a host of other items. The heartburn is supposed to be due to the reflux of acidic digestive juices from the stomach into the gullet or esophagus. There is no true physical barrier between the stomach and the lower esophagus like a trap door but there are a group of muscles known as the lower esophageal sphincter. These muscles are supposed to recognize that the stomach contains food and acidic digestive juices and contract and prevent the stomach contents from kicking back up the esophagus and producing heartburn symptoms.

The treatments of choice are; avoiding those foods that produce the heartburn, wearing less constrictive clothing and, medications. The gold standard of medications is the PPI’s or proton pump inhibitors. These would be medicines like Prilosec, Nexium, and Prevacid. The product inserts suggests we take these medications for eight weeks and no longer. Most patients continue to take the medications long after the recommended eight weeks.

In an interview in MedPage, the online journal of the University Of Pennsylvania School Of Medicine, David Kleiman, MD of Weill Cornell Medical College in New York City proposes that at eight weeks patients be given a pH test or what used to be called the “Bernstein Test”.

With the pH test, a thin plastic tube is inserted through the nose and placed so the tip is at the lower portion of the esophagus adjacent to the stomach. You then sample and test the fluid for acidity by measuring its pH. The test costs under $700 and is fairly accurate and safe.

According to Dr. Kleiman, he examined patients with GERD who continued to take PPI’s beyond eight weeks and almost 1/3 of them did not have any signs of acidic material refluxing into the esophagus. When looking at the lower dose PPI’s sold over the counter, versus the prescription items, the average weekly cost of PPI’s varies from $29 to $107. This translates to a cost of between $2000 and $7,300 a year on medicines not needed.

While the idea of inserting a tube to measure acidity as a way to distinguish who should continue PPI’s has its merits, the practical question is “How available is the test and who is doing it?”.

It is always a good idea to discontinue medications you do not need – especially expensive ones. The availability of the testing in local communities may preclude this approach.