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Benefits and Risks of Acid Reflux Medications: Proton pump inhibitors are appropriate for some patients but not for others.

Heartburn is the most common symptom of acid reflux, which occurs when stomach acid comes up into the esophagus. Millions of Americans suffer from heartburn, which many experience as a source of occasional minor discomfort. But there are times when heartburn should be viewed as a cause for concern rather than as a periodic annoyance.

"If you have heartburn regularly more than twice a week, you probably have a condition called gastroesophageal reflux disease (GERD). Heartburn that occurs infrequently is often referred to as "episodic heartburn" and is not necessarily considered a disease," explains Philip Katz, MD, a gastroenterologist and professor of medicine at Weill Cornell Medical College. Many people can take over-the-counter (OTC) medications, including proton pump inhibitors, or PPIs, to ease episodic heartburn, and many people diagnosed with GERD take PPIs as well.

Medication Options

PPIs block acid production; they are the most commonly prescribed drugs for GERD. PPIs include lansoprazole (Prevacid), omeprazole (Prilosec, Zegerid), esomeprazole (Nexium), pantoprazole (Protonix), rabeprazole (Aciphex), and dexlansoprazole (Dexilant). The first three of these are available in both OTC and prescription form in the U.S.

Other medications for GERD include antacids, such as Mylanta, Rolaids, and Turns, that neutralize stomach acid. They may provide quick relief, but their effects aren't long-lasting. H2 receptor blockers are drugs that reduce acid production; they include cimetidine (Tagamet), famotidine (Pepcid), k nizatidine (Axid), and ranitidine (Zantac). H2 receptor blockers may decrease acid production for up to 12 hours; they are available OTC and by prescription.

However, many people who have GERD find that PPIs are the most effective at easing their heartburn and other GERD symptoms, which may include a chronic cough, a voice change, swallowing problems, and a sour or metallic taste in your mouth. But there is growing concern about the possible long-term effects of PPIs, which have been linked with serious side effects, including higher risks of bone fracture.

PPI Warnings

The first PPI, omeprazole, was approved by the U.S. Food and Drug Administration (FDA) in the late 1980s. Over the years, more PPIs have been developed, and more data on the long-term effects of PPIs have become available, revealing associations between the use of PPIs and several adverse events.

"Acid is produced in a single cell in the stomach called the parietal cell, which pumps the acid into the stomach. PPIs block the terminal step in acid production. When you inhibit acid, there's concern that you might affect the absorption of several nutrients, including vitamin B12, iron, and calcium, the latter perhaps contributing to a higher fracture risk," explains Dr. Katz.

The FDA requires that PPI packaging carry warnings about possible serious side effects, including increased risk of fracture of the hip, wrist, and spine, diarrhea caused by the bacterium Clostridium difficile, and low magnesium levels. And recent research suggests that taking a PPI may inhibit the action of clopidogrel (Plavix), a drug designed to prevent blood clotting.

However, Dr. Katz notes that direct causality between PPIs and these conditions has not been proven, and there are conflicting studies that refute some of these concerns.

Is a PPI Right for You?

There is no one-size-fits-all answer to the question of whether or not you should take (or continue to take) a PPI.

"Each individual must work with his or her provider to assess the benefits and risks given his or her GERD severity and consider all of the alternatives available to treat the disease," advises Dr. Katz. "People should not be told that everyone who is on a PPI should ultimately try to discontinue it. In many patients, the risk of discontinuing or reducing the dose may do more harm than good."

Inappropriate use of PPIs occurs when they are prescribed for conditions in which acid control is not required, or for people with mild reflux who may not need a PPI. Often, people stay on PPIs without guidance from their physicians or a clear need for the drug.

"OTC PPIs are intended to be taken for no more than two weeks at a time. If you need PPIs longer than this, see your doctor and ask if you are taking the drug for the right reason. Also, your doctor can tailor the treatment to your needs by determining if and how often you should take a PPI and what dose is appropriate for you," says Dr. Katz.

Other GERD Treatments

In some cases, GERD also may be treated surgically.

Fundoplication is a procedure in which the surgeon wraps the top of the stomach around the lower esophageal sphincter (LES) to tighten the LES and prevent reflux. Fundoplication is usually done with a minimally invasive (laparoscopic) procedure. Dr. Katz notes that this procedure has excellent success when performed by an experienced surgeon.

A newer procedure to treat GERD is called magnetic sphincter augmentation. A ring of small magnetic beads called a Linx device is wrapped around the junction of the stomach and esophagus, where the LES is located. The magnetic attraction between the beads is strong enough to keep the LES closed to refluxing acid, but weak enough to allow food to pass through. The Linx device is implanted using a laparoscopic procedure.

And there's a procedure that requires no incisions.

"Transoral incisionless fundoplication (TIF) is a procedure that can be performed through an endoscope (a small, flexible tube that is fed through the esophagus down to the stomach), creating a partial fundoplication. In the right patient, a decrease or elimination of the need for a PPI may result," explains Dr. Katz.

"Lifestyle changes also can be helpful; for example, about 25 percent of patients with GERD have significant improvements with dietary changes. Lose weight, don't eat late, eat more slowly--all of these strategies can help," says Dr. Katz. "However, it's important to understand that GERD is not a diet-induced disease; certain foods may give you heartburn, but they do not cause GERD."

In a normal stomach, acid can't go up into the esophagus because the lower esophageal sphincter is closed.

Lower Esophageal sphincter


Stomach Acid

If you have GERD, the lower esophageal sphincter sometimes remains open, allowing acid to go up into the esophagus.


To prevent or ease GERD symptoms:

> Eat at least three hours before going to bed or lying down.

> Eat slowly and chew your food thoroughly.

> If you often have nighttime heartburn, raise the head of your bed by placing a foam wedge under the top part of your mattress.

> If you're overweight, lose weight. Losing weight reduces and even eliminates GERD symptoms in some patients.

Caption: The Linx device is a small ring of magnets that is placed around your lower esophageal sphincter; it opens to allow food into your stomach but stays closed at) other times to prevent acid reflux.
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Publication:Women's Health Advisor
Date:Jul 1, 2019
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