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If PPIs are so great, why...

First off, let me say that PPIs (Prilosec, Nexium, Protonix, Prevacid, Aciphex, Dexilant, etc.)have revolutionized the way we treat and prevent many gastrointestinal disorders. Primary among them- peptic ulcer disease (gastric and duodenal ulcers), erosive esophagitis, and H. pylori infections. Here are the FDA approved indications for PPIs:

    • Healing of erosive esophagitis (EE)
    • Maintenance of healed EE
    • Short-term treatment of gastroesophageal reflux disease (GERD)
    • Risk reduction for gastric ulcer (GU) associated with nonsteroidal anti-inflammatory drugs (NSAIDs) • Helicobacter pylori(H. pylori) eradication to reduce the risk of duodenal ulcer (DU) recurrence, in combination with antibiotics
    • Pathological hypersecretory conditions, including Zollinger-Ellison (ZE) syndrome
    • Short-term treatment and maintenance of DUs

Most experts agree that PPIs are grossly over prescribed and managed poorly once they are. Optimizing medical therapy for GERD is a complex issue that challenges even the most well-practiced providers. Additionally, this is doubly true when patients are self-managing their GERD with PPIs or H2 blockers. While PPIs have improved the symptomatic treatment of GERD and other disorders described above, they are not without their side effects. Hopefully this will stir some debate.

If PPIs are so great, why…

    • has esophageal adenocarcinoma increased by 600% since 1975?
    • do 30-40% of patients have breakthrough symptoms?
    • has the FDA issued 3 safety communications concerning long-term use?
    • have recent studies implicated PPI use with increased risk of cardiovascular events (stroke and heart attack) and significantly decreased survival?
    • do patients progress at alarming rates from simple GERD to Barrett’s esophagus (considered a pre-cancerous condition) despite PPI use?
    • did a recent study in nearly 10,000 patients find higher rates of esophageal cancer in Barrett’s patients when they took PPIs as prescribed vs patients who took less or none?
    • have recent studies linked PPI use to higher rates of community acquired pneumonia?
    • is there not a single health benefit to PPI use

Please click here to learn more about the complications of GERD.

Here is what the Harvard Medical School Health Letter says about PPIs-

“PPIs are the most potent inhibitors of stomach acid available, and they’re a welcome addition to the medical armamentarium. But every pill — indeed, every medical intervention — is a risk-benefit balancing act. The PPI-clopidogrel interaction seems to be less important than once feared, but there are other reasons to be cautious about PPIs. You don’t need to take a PPI for the incidental case of heartburn. If you have a prescription, the reasons for it should be reviewed periodically to make sure they’re still valid; it’s common for people to take medications far longer than is necessary, and that is particularly true of the PPIs.”

The bottom line is that PPI use in patients with GERD should be viewed as such:

  • They can help heal erosive esophagitis in the short-term, BUT they only function to decrease acid; there are many other harmful components of refluxed contents from the stomach.
  • They treat a symptom, heartburn, BUT they do not treat the D (Disease) in GERD.
  • They do NOT stop progression of disease to Barrett’s esophagus and/or esophageal cancer because they do NOT stop gastro-esophageal reflux.

Think about this if you are on long-term therapy.

Tripp Buckley, MD

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