Alternatives to Proton Pump Inhibitors

Alternatives to Proton Pump Inhibitors

I was going to address allergy supplements next, but because of the recent press on the increased risks of death with Proton Pump Inhibitors (PPI), I’m going to tackle this next!

Most likely you or someone you know has taken a PPI at some point in their life. I have (I wish I hadn’t), but as a college student in a traditional pharmacy program, I had no idea the implications it might have down the road. Currently proton pump inhibitors account for over $10 billion dollars in annual healthcare cost and are consistently within the top ten most prescribed medications. Common names for PPIs are below.

Prilosec® (Omeprazole)

Nexium® (Esomeprazole)

Prevacid® (Lansoprazole)

Protonix® (Pantoprazole)

Dexilant® (Dexlansoprazole)

Aciphex® (Rabeprazole)

What is a PPI? They are medications that reduce the secretion of acid in the stomach. And in many cases they may be needed to heal conditions such as erosive esophagitis (a condition where the lining of the throat is worn away) or peptic ulcers (small holes in the intestinal lining) and they may be needed long term for Barrett’s esophagus. Other conditions may be able to be treated with PPIs short term and then other methods likely can be used after healing has occurred.

The challenge with this is that our bodies are designed to have secretion of acid start the steps needed for proper digestion. So when we stop the initial acid trigger, we decrease production of digestive enzymes and other processes down the line. Then large food particles are undigested leading to a “leaky gut” which I will have another post on very soon by a guest (another pharmacist blogger!) Since we now know gut health is such an important underlying piece to a variety of health conditions, this may be why we see issues with the use of PPIs.

The most recent study⁸ was a longitudinal observational study in a Veterans Affairs population. The follow-up time frame was on average 5.71 years. Researchers compared patients on PPIs to patients on histamine H2 receptor antagonists (most commonly used drugs in this category are as Zantac (raniditine) and Pepcid (famotidine)), and patients without either medication. The results suggest excess risk of death among PPI users; risk is also increased among those without gastrointestinal conditions and with extended duration of use. The authors suggested limiting PPI use and duration to instances where it is medically indicated may be warranted. Other risks associated with PPIs are in the table below.

Risk	Rationale
Impaired Nutrient Absorption 9,10	The long-term use of PPIs may impair the absorption of calcium, magnesium, iron, and vitamin B12 among other nutrients. These effects usually do not appear to be clinically relevant; however, there is speculation that some of these effects contribute to some of the other risks of PPIs.
Osteoporosis 11-14	PPIs have been linked to increased risk of fracture in several observational studies. This may be due to impaired calcium absorption; however, the exact mechanism has not been well-established.
Kidney Disease 15,16	PPIs have been implicated in both acute and chronic kidney disease. Again this is mostly observational data, but dose-response relationships have been demonstrated. PPIs appear to increase the risk of kidney disease; however, the mechanism for this is not well understood. There are some case reports of PPIs inducing acute interstitial nephritis, which may contribute.
Dementia and Functional Decline 17-19	PPIs have been associated with increased risk of functional decline and loss of activities of daily living. PPIs have also been associated with an increased risk of dementia including Alzheimer’s disease. Both of these links are difficult to prove, and the evidence out there has bias and limitations. Still, studies have shown that patients using a PPI before diagnosis were 40% more likely to be diagnosed with dementia.
Pneumonia 20	Observational evidence has shown a 50% increase in risk of developing community acquired pneumonia in patients taking a PPI. This risk may not be relevant after controlling for cofactors.
Clostridium Difficile 21,22	There is evidence that PPIs may increase C Diff risk by 74%. This increases to 96% when PPIs are given along with antibiotics. H2RAs have been shown to have a lower risk compared to PPIs. There is also some evidence in mice that PPI use aggravates inflammation associated with C Diff infections.
Heart Attack 23	PPI use has been shown to be associated with a 15% increase in risk of heart attack. This was observational data, and there is some argument that this increase in risk may be related to physicians mistaking dyspepsia for an MI.
Stroke 24	A recent abstract from the American Heart Association’s 2016 meeting demonstrated a 21% increased risk in ischemic stroke for patients taking PPIs. The abstract also notes a dose-response relationship.

So the question is, I don’t have erosive disease, I’m just on this medication for heartburn/acid reflux.. how do I get off?

When patients discontinue a PPI, they may experience some rebound acid reflux. PPIs increase a hormone called gastrin, which would normally signal the production of acid; however, while patients are taking the PPI this effect is suppressed. Following the withdrawal of the PPI, the elevated gastrin can cause a rebound increased in acid secretion. The effects tend to last for one to two weeks.^25,26

When discontinuing a PPI…

• Talk with your healthcare provider to consider titrating it down; in other words slowly decreasing it.
• Recognize that heartburn may return for the first week or two.
• You could consider using OTC Antacids (like Tums) or H2RAs (like Ranitidine or Famotidine) for 1-2 weeks to help with the rebound effect.
• Consider supplements and alternative options.

Alternative Options

Product	Directions	Rationale
Apple Cider Vinegar 27	Take 1-2 teaspoons in a glass of water before meals. (drink with a straw to avoid erosion to teeth)	Some theories for how heartburn develops suggest that heartburn can happen as a result of not having enough stomach acid to properly digest food. Adding a small amount of the acidic apple cider vinegar may help reduce symptoms.
Probiotics 27	Aim for at least 10 to 20 billion CFUs per day.	Heartburn symptoms could be due to an imbalance of GI bacteria. Probiotics can help restore the balance of GI flora and improve digestion. Various bacteria play different roles in digestion.
Digestive Enzymes 28	Take 1 capsule with meals.	Poor digestion may make heartburn symptoms worse. Adding digestive enzymes can aid digestion and prevent symptoms.
DGL 29-31	Take 1 capsule once daily with a meal.	Soothes gut lining, stimulates proper digestion.
GI Revive 29-35 (Contains DGL and other ingredients)	Take 7 capsules daily; These can be spaced out however the patient tolerates them. It may be beneficial to take them with meals.	GI Revive can help heal the gut if damage or “leaky gut” is suspected. The theory is that since most of the immune system lies in the gut, if there is damage and large inflammatory particles get through, patients will experience inflammation and GI symptoms.
DGL by OrthoMolecular 29-31, 36-40	1-2 tablets per day	Soothes gut lining, stimulates proper digestion. Marshmallow root has a long history of providing a soothing property to mucous membranes. Slippery elm bark also helps protect the GI tract and promotes a healthy cycle of inflammation. Aloe Vera has studies that show it helps balance gastric acid secretion and at low doses protects the membranes from excess acid.
Heartburn Essentials 29-31, 36-37	1 capsule with each meal	Has DGL, marshmallow root, slippery elm, artichoke, and turmeric plus digestive enzymes.

In our practice we typically use GI Revive for patients with suspected leaky gut and inflammation in the gut because it has good nutrients for helping to restore tissues such as zinc carnosine, l-glutamine, and N-Acetyl Glucosamine. As well as some anti-inflammatory supplements like MSM and Quercetin. Then it also has some of the similar ingredients to other products above such as DGL, slippery elm, and marshmallow root, etc. I typically do it for 1-2 months then move on to something a bit less expensive for maintenance if needed. Again this is for patients with inflammation present and you may not know that unless you work with a provider who can do some functional medicine testing.

For most patients with occasional heart burn and reflux without other symptoms of “leaky gut” starting with DGL may be enough. I like the Orthomolecular product that also includes slippery elm bark, marshmallow root, and aloe vera. There is a similar product called Heartburn Essentials by Pure Encapsulations noted in the table as well.

If you aren’t taking the GI Revive, it may be worth considering adding Zinc Carnosine.  It is a great nutrient for helping re-build the mucosal lining. It also has anti-ulcerative properties.

In summary for most patients trying to get off a PPI (without evidence of erosive disease)

I would recommend discussing the following with your health-care provider.

• A quality probiotic like OrthoBiotic from OrthoMolecular (I like that this doesn’t need to be in the fridge and includes Saccharomyces Boulardii) or Ther-Biotic Complete Klaire Labs
• Digestive Enzymes take your pick of products, I have some of my favorites listed in my Full Script store. If you have symptoms that include a “burning sensation” at this time, you likely want to avoid a product with HCL until soothing nutrients have allowed the mucous membranes to heal.
• Deglycyrrhizinated licorice (DGL) (The Orthomolecular product or plain DGL) OR the Heartburn Essentials (Pure Encapsulations).

Also consider

• Zinc carnosine  if not taking GI Revive
• Ox Bile if your heartburn is worse after fatty meals and you have trouble digesting those, you could add  Ox bile 125 mg with fatty meals. The OrthoDigestzyme product has this in it already but also has HCL.

You can find these in my FullScript Supplement store under the “GastroIntestinal Health” category.

Additional things to consider would be acupuncture, chiropractic care, or osteopathic manipulation with a DO physician. The human body never ceases to amaze me, that God created each part of us to work together, to balance our bodies. If one area is out of whack, it often affects other processes in the body. I have found all three to be helpful at different points in my life. Lastly in the list below, there are some other ideas that are non-medication or non-supplement related steps reducing heartburn as well.

Next steps…. if no improvement you may want to consider doing a stool test with a practitioner. This will discover if you have inflammation in the gut, an imbalance in bacteria, yeast or an invader like a parasite contributing to symptoms. It also shows you if you have undigested proteins and fats in the stool.  You can find a provider in your area here.

I hope you find this helpful! A HUGE thank you to a past student of mine Dr. Trevor Stump for compiling a lot of this information. He shared with our team of local providers earlier this year.

[drh]

Non-Pharmacological Recommendations for Heartburn

• Weight Loss
• Smoking Cessation (Quitting Smoking)
• Avoiding Spicy or Fatty Foods
• Eating Smaller Meals
• Avoiding Tight Clothing
• Elevating the Head of the Bed at Night
• Avoiding Meals within 3 Hours of Bedtime
• Yoga or Meditation (Stress Relief)
• Eating More Slowly

*this post contains affiliate links to products I recommend, all the supplements recommended in this post can be found in my FullScript Store You do have to set-up a quick account to use.  Thanks for supporting the blog, remember 10% goes to support various ministries! Check out My Favorite Things for more details. Reminder that this information is general and personal specific health decisions should be made between you and your medical provider. Remember supplements can interact with certain medications, so make sure to include a pharmacist knowledgeable in this area in your decisions as well.

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