Dear NP

Dear NP,

“I have been taking proton pump inhibitors (PPI) for heartburn daily for the last seven years. My healthcare provider has advised me to stop due to possible serious side effects. What are these side effects and are they in fact serious?” M. E.

Dear M. E.,

Heartburn can be painful and difficult to have even once, but to people with gastroesophageal reflux disease (GERD), heartburn can become a daily nightmare. GERD occurs when acid from the stomach works its way into the esophagus and can cause significant burning and irritation in the chest and throat.

For people with GERD, proton-pump inhibitors (PPIs) offer one solution to the problem. These medications, which include drugs like omeprazole (Prilosec) and pantoprazole (Protonix), work by slowing the production of stomach acid by the cells in your stomach. With less acid in the stomach, there’s less acid to back up into the esophagus and cause heartburn irritation.

Many patients with GERD can see relief with a two-week course of over-the-counter PPIs. However, some patients like you with severe GERD do end up taking these medications long term through a prescription from their healthcare provider.

In many cases, it’s perfectly alright to stop taking the medication by tapering off if you’re no longer showing GERD symptoms. This is especially true if you’ve made lifestyle changes that reduce the symptoms of GERD. Some of these include:

• Weight loss. Being overweight is the leading cause of GERD.

• Eating frequent smaller meals instead of large meals.

• Not eating before bedtime.

• Sleeping with your upper body elevated above stomach level. This causes less acid to enter the esophagus by reducing the pressure on the opening between the stomach and the base of the esophagus.

• Avoid highly acidic, fatty and spicy foods. These can easily trigger another bout of acid reflux.

• Also avoid mint. Mint may make acid reflux more frequent by loosening the passage between the stomach and the esophagus.

If you haven’t made these changes, these may be a good thing to discuss with your healthcare provider before stopping PPI use. Many of these lifestyle choices are healthy in general, so they can’t hurt.

Because it’s effectively impossible for a PPI medication to completely stop the production of stomach acid, PPI’s are very safe medications. However, their long term may be associated with certain serious side effects. These are what your healthcare provider warned you about.

Long term use of PPIs has been associated with increased risk of developing a type of pneumonia called aspiration pneumonia, as well as increased risk of infection by a potentially serious gut bacterium called C. difficile. This is because these types of bacteria are usually controlled by stomach acid and reducing the production of acid allows them to reproduce much more rapidly and cause infection.

Another side effect of long-term PPI use is that it may also cause you not to absorb enough calcium, magnesium, vitamin B12 or iron, which may result in an increased risk of certain kinds of fractures as well as overall vitamin deficiency.

Both of these major sets of side effects are a consequence of the fact that PPIs reduce the production of stomach acid. This is great for reducing irritation and discomfort at acid reflux but can also reduce the ability of the stomach to do its normal functions like regulating gut bacteria and absorbing vitamins and minerals.

So, whether to continue long-term use of PPIs is really a tradeoff between symptom relief and the reduction of regular stomach function. Talk to your healthcare provider about how your lifestyle might be affecting your GERD and whether lifestyle changes may allow you to taper off of PPIs. Also, be sure to ask about whether you have any other risk factors for side effects like pneumonia or increased risk of fractures. Your healthcare provider may have warned you for a reason.

And as always, never make any medical decisions without consulting your healthcare provider.

Dr. Wesley Davis is an Emergency Nurse Practitioner at Crook County Medical Services District and Coordinator of the Family and Emergency Nurse Practitioner program at the University of South Alabama. He encourages readers to send their questions to [email protected]