Navigating Long-Term GERD Management: Is This Common Treatment for Reflux Doing More Harm Than Good?

MEDICINE
Written By Samantha O'Connor

If you're like 20% of Americans, you may have a condition called Gastroesophageal Reflux Disease (GERD).¹ This unpleasant condition is also called acid reflux or heartburn. It's caused by a combination of increased acid production in the stomach and the "reflux" of that acid out of the stomach and into the esophagus (the tube that carries food from the mouth down to the stomach). 

In my last blog, which you can read here, I discussed the different treatment options for GERD, which include various medications and lifestyle changes. The focus of treatment is to decrease the amount of acid that leaks out of the stomach, and the main way this is done is by reducing acid production altogether. This is how many of the medications that treat GERD work.

One of the main types of medications used to treat GERD are called proton pump inhibitors (PPIs). Even though it's recommended that they be used after trialing other medications, I still see that they're often the first to be used.

In fact, PPIs are used so much that they're one of the top 10 most prescribed medications in America.²

Why is this? Well, from what many patients have told me, it's because they seem to work much better than the other medications for GERD, like Antacids and H2 blockers (histamine 2 blockers).

But did you know that, in most cases, it's not recommended to take PPIs longer than eight weeks?

Despite this, many people have been on PPIs for years.

But the long-term use of PPIs has been linked to many medical conditions including:

  • Life-threatening vitamin and mineral deficiencies 

  • Osteoporosis (thinning of the bone)

  • Kidney disease

  • Certain types of infections

  • Certain types of cancer

Because of this, I often recommend for patients to use these medications sparingly and to try other treatment options for their GERD. But if you've been taking a PPI for years, it can be difficult to stop taking it, as the symptoms of GERD come back with a vengeance. This is something called rebound hyperacidity, and PPIs are a known culprit of it.³

For this reason, there are different ways to slowly taper off of PPIs, and I'll discuss this later on. If you've been taking a PPI for longer than eight weeks, I want to make you aware of the long term-side effects and complications of PPIs, as some of them can be dangerous and life-threatening. 

Long Term Use of PPIs For GERD: Key Takeaways

  • The treatment for acid reflux is aimed at reducing the amount of acid your stomach makes, which then improves the symptoms of reflux.

  • It's important to properly treat gastroesophageal reflux disease to prevent long-term damage and inflammation of the stomach and esophagus, but it's important to remember that some medications can have long-term negative effects. 

  • Unless you have certain conditions such as erosive esophagitis or peptic ulcer disease, it's recommended to take PPIs for no longer than eight weeks at a time.

  • Taking PPIs for longer than eight weeks can increase your risk of vitamin and mineral deficiencies, thinning of the bones, infections, and possibly cancer.

  • Stopping a PPI can be difficult, but there are several ways to taper off of your PPI and use other prescription and over-the-counter medications as needed for your GERD symptoms.

  • Always talk to your doctor before making any changes to your medications.

What Are Proton Pump Inhibitors?

Proton pump inhibitors are one of the types of medications used to treat GERD. These medications can help by decreasing the amount of gastric acid produced by cells in the lining of the stomach. These acid-producing cells are called parietal cells. 

The majority of the unpleasant symptoms from GERD are a result of increased acid secretion in the stomach as well as the leakage of acid out of the stomach and into the esophagus.

What Are the Symptoms of Acid Reflux?

Some of the common symptoms of acid reflux or GERD include:⁴

  • Indigestion

  • Nausea

  • Bloating

  • Sore throat

  • The feeling of a lump in your throat

  • Upper abdominal pain

In addition to these symptoms, chronic reflux can result in inflammation and damage to the esophageal lining, which is called esophagitis.

What Are the Complications of Long-Term PPI Use?

While it is important to treat reflux, PPIs are not recommended to be the first choice. When compared to other medications that treat GERD, PPIs block the production of acid in all three acid pumps in the stomach while H2 blockers only partially block the amount of acid produced.³

Taking a PPI lowers the amount of stomach acid that's produced. And while this is great for reducing the symptoms of GERD, it's not good for our health. 

Without stomach acid we wouldn't be able to digest food and get the essential vitamins and minerals from food that we need to live. This is the crux of what causes many of the side effects and complications of long-term PPI use. 

In addition to this, the long-term use of PPIs is also related to an increased risk of certain infections, chronic illness, and cancer. Here are six complications of long-term PPI use.

1. Low Magnesium Levels

When you take a PPI, you decrease the production of stomach acid, which makes it harder for your body to break down and absorb vitamins and minerals. One of the minerals that's greatly affected by taking PPIs is magnesium.

Our bodies need magnesium for many reasons including:⁵

  • Regulating muscle and nerve function

  • Managing blood sugar levels

  • Controlling blood pressure

  • Making protein

  • Building bone

  • Creating DNA

A healthy range of magnesium in the blood is 1.46 to 2.68 mg/dL. Levels of magnesium below 1.46 mg/dL are considered low, which is a term called hypomagnesemia. When levels decrease below 1.2 mg/dL, that's when things can really start to go wrong.⁶

When magnesium levels are too low, it can cause serious and threatening complications including:⁷

  • Seizures

  • Muscle weakness

  • Sudden confusion and altered mental status (delirium)

  • Abnormal heart rhythms (cardiac arrhythmias)

Additionally, magnesium is needed to regulate other electrolytes. Low levels of magnesium can also cause low levels of calcium (hypocalcemia) and potassium (hypokalemia).

A review was done that looked at 109,798 patients, and it found that patients taking PPIs had a 43% higher risk of having low levels of magnesium compared to patients that did not take a PPI.⁷

Additionally, it's been found that if you have low levels of magnesium while on a PPI, taking a magnesium supplement will not improve levels of magnesium enough. The only way to fix hypomagnesemia caused by a PPI is to stop taking the PPI.

2. Low Vitamin B12 Levels

One vitamin that can be affected by being on a PPI is vitamin B12. In order for vitamin B12 to be absorbed in the stomach, an acidic environment is needed. So by taking a PPI that lowers acid secretion in the stomach, this can interfere with the absorption of vitamin B12.⁸

Vitamin B12 is needed for healthy functioning of the brain and nerves. Low vitamin B12 levels can cause symptoms such as:⁹

  • Fatigue 

  • Tingling in the fingers and toes

  • Weak muscles

  • Trouble walking

  • Nausea

  • Weight loss

  • Mood changes

  • Increased heart rate

A large study showed that adults that took a PPI for more than two years had a 65% increased risk of having low levels of vitamin B12.¹⁰

3. Increased Risk of Osteoporosis

Calcium is another mineral that needs an acidic environment to be properly absorbed. So by decreasing acid production in the stomach with a PPI, this can cause decreased absorption of calcium. 

When our bodies don't get enough calcium, this can lead to a condition called osteoporosis. Osteoporosis is a medical condition that's defined as decreased bone density, and it's associated with long-term PPI use. Osteoporosis is typically seen in people over the age of 65 years, and it's more common in females than males. 

Just a side note: osteoporosis is more common in females due to hormonal changes that happen following menopause. When females go through menopause, their estrogen levels drop, and estrogen is one hormone that prevents the breakdown and thinning of bones.

You've also probably heard of osteopenia, and it's a condition of bone thinning that happens before a diagnosis of osteoporosis. Both conditions are diagnosed with a test called a DEXA scan, which measures bone density. Depending on the severity of your bone density, you may be diagnosed with osteopenia or osteoporosis. 

Taking a PPI has been shown to increase the risk of developing osteoporosis and breaking a bone.¹¹ And you don't have to be on a PPI for several years to be at an increased risk of breaking a bone. Studies have shown that taking a PPI for just one year or more increases the risk of breaking a bone.²

4. Increased Risk of Infections

Using PPIs has been shown to increase the risk of developing certain types of infections, and it all comes down to how PPIs decrease the amount of acid your stomach makes. 

Not only does stomach acid digest food and help our bodies absorb vitamins and minerals, but it also prevents bacteria and viruses from reaching other parts of our bodies. Our stomach acid works as a barrier to keep harmful organisms from traveling to other parts of our bodies, especially our intestines. 

However, when you're not making as much stomach acid, this barrier isn't effective. This increases the risk of developing certain infections, and one of them is called Clostridium difficile colitis (AKA C. diff), which is a bacterial infection of the colon. The same idea goes for any type of food-borne illness (food poisoning).

Research has shown that one major risk factor for developing an infection caused by C. diff is the long-term use of PPIs.²

5. Stomach Cancer

While the relationship between PPI use and the risk of developing stomach cancer hasn’t been confirmed in humans, it's been studied in rats. It’s thought that by decreasing stomach acid production with PPIs, the production of a chemical called gastrin increases.

Gastrin is one of the chemicals responsible for telling the body to make stomach acid, and it’s also responsible for the growth of some of the cells that line the stomach.

Because of this, high levels of gastrin have been associated with an increased risk of certain stomach cancers in rats. Research has been done on the relationship between long-term PPI use, but the results have been confusing. Some studies have shown that long-term PPI use may increase the risk of stomach cancer, while other studies have shown no increase in risk of stomach cancer.⁸

Due to these conflicting results, it’s hard to say whether or not long-term PPI use increases the risk of stomach cancer in humans.

6. Increased Risk of Kidney Disease

The use of PPIs has also been shown to increase the risk of developing kidney disease.

A study published in 2019 looked at 192,936 people to see if being on a PPI increased the risk of developing kidney disease. What they found was that even though people did not have a history of kidney problems, people taking a PPI had a 20% higher risk of developing chronic kidney disease than people not taking a PPI.¹²

This study also mentioned a statistic that up to 70% of patients are taking PPIs without a valid indication. This is shocking, but not surprising, to me, and it definitely shows the need to consider stopping your PPI.

How To Stop a PPI When You Have Chronic Acid Reflux

If you're a patient with severe reflux symptoms, you may be wondering how you can stop your PPI without having severe heartburn. Fortunately, there are ways to slowly taper off of PPIs. It may just take a bit of time and patience. 

Please note that you should talk to your doctor before stopping any medications used for GERD treatment. 

If you take the medication pantoprazole at a dose of 40mg twice daily, here is an example of a taper schedule:

  • Week 1: Decrease dose to 40mg once daily

  • Week 2: Decrease dose to 20mg once daily

  • Week 3: Decrease dose to 20mg every other day

  • Week 4: Stop pantoprazole

You can typically decrease the dose every week, but if you have chronic acid reflux and you've been on a high dose of a PPI for a long time, you may need to decrease the dose every two to three weeks instead.

Please note that increased stomach acid production (rebound hyperacidity) is common when people stop taking PPIs. If this occurs for you, you can expect these worsening symptoms to last for about two weeks. 

If you notice that reflux symptoms occur during the taper, you can use certain over-the-counter or prescription medications as needed for symptoms. Some of these medications include:

  • Pepcid (famotidine), Tagamet HB (cimetidine), and Axid AR (nizatidine), which are H2 blockers

  • Tums, Mylanta, and Rolaids, which are antacids

If symptoms persist after the taper, other treatment options besides PPIs are available. 

Treatment Options For GERD Without a PPI

The treatment approach for GERD focuses on minimizing symptoms while keeping enough acid in the stomach to properly digest food and absorb vitamins and minerals. 

As I mentioned, there are other medications commonly used to treat GERD that are available by prescription or over-the-counter. These types of medications include antacids and H2 blockers. 

Because H2 blockers only partially block the production of acid in the stomach, they allow for better absorption of vitamins and minerals. Antacids don't cause stomach acid suppression. Instead, they work to neutralize stomach acid. Both types of medications are great to use on an as-needed basis. 

Additionally, there are also many lifestyle changes you can make to improve your reflux symptoms. The most impactful lifestyle change is weight loss, and you can read more about it in my last article: How to Treat Acid Reflux: Lifestyle Changes and Medication.

Please remember to talk to your doctor if you have any concerning gastrointestinal (GI) symptoms such as: 

  • Difficulty swallowing

  • Painful swallowing

  • Blood in your stool, which can present like bright red stool or dark red/black stool

  • Weight loss

  • Getting full quickly

These symptoms can be a sign of a life-threatening condition such as bleeding in the GI tract or cancer. If you have blood in your stool of any kind, it’s recommended that you present to the nearest emergency department as soon as possible. The other symptoms listed above are serious as well, and your doctor may recommend seeing a gastroenterologist (stomach and intestine doctor) for further evaluation. 

I hope that this article is helpful for you and can serve as a reference for any questions and concerns you may have about taking PPIs. If you have a thought or question, I'd love to hear from you! Just complete the "contact me" form by clicking the link below.

Make sure to check out some of my other articles to get more up-to-date, evidence-based information about health and wellness. If you want to be notified when I post a new article, sign up for my mailing list at the link below. Don’t worry, I won’t bombard you with emails. And who knows? You just might learn a thing or two.

Stay informed, stay healthy.

Samantha O'Connor
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