By Dr. Marvin Singh, MD
September 3rd, 2018
As an Integrative Gastroenterologist, heartburn or acid reflux is one of the most common topics of discussion. There are all kinds of news reports that acid reflux medications like PPIs (Proton Pump Inhibitors) can cause anything from kidney failure to dementia. Is there any truth to this? Is there anything else that can be done? Well, yes, there is definitely something that can be done. And there are definitely some associations with some of these conditions.
Acid reflux and heartburn are basically the same thing; we use the term interchangeably. It basically means that stomach acid and bile can flow up from the stomach to the esophagus (food pipe). This can be a really uncomfortable feeling and can cause burning under the chest. The traditional go to medications have been things like TUMS or Zantac (ranitidine). Now that several proton pump inhibitors (PPIs) are over the counter, these have become much more readily used although they are still, and have always been, very widely prescribed. A proton pump inhibitor (PPI) reduces the production of stomach acid. They help us feel better, so we take them. End of story? Not exactly…..
We need the acid in our stomach. We were born to produce acid in our stomach so that we can digest and process the food we eat. So, what happens when you do something to counter that effect? Well, there have been a whole host of health effects noted or found to be associated with use of these PPI medications. These include: B12 deficiency, osteoporosis, kidney dysfunction, dementia, low magnesium levels, small intestinal bacterial overgrowth (SIBO), increased risk of getting a stomach bug, and increased risk of a potentially significant diarrheal infection from Clostridium difficile. There have been reports of low magnesium induced low parathyroid function (https://www.ncbi.nlm.nih.gov/pubmed/26069375). While there is no definitive consensus on the role of PPIs in dementia, there is some information to raise suspicion that PPIs could play a role in the development of dementia, perhaps as a result of drug-drug interactions and/or effects on electrochemical gradients in neurons, among other possibilities (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5883984/). Risk of acute kidney injury and chronic kidney disease is also something well described. I have personally seen patients develop kidney failure and no other reason could be determined besides the use of a PPI. It is well established that an allergic kidney injury called acute interstitial nephritis can occur. Although we need more research to definitively establish that kidney failure and chronic kidney disease can result from use of PPIs, there are enough reports demonstrating association that should raise our eyebrows (https://www.ncbi.nlm.nih.gov/pubmed/29668562).
The literature and reports go on and on. I could probably write a book on it! The point, though, is that these medications may have a role in management of some things but they were not truly meant to be taken for long periods of time. However, many of us do take them for long periods of time. The problem is that we are now learning about things that could happen that we didn’t anticipate would happen. What we are likely doing is manipulating our gut microbiome. The gut microbiome is the ecosystem of over 100 trillion bacteria, viruses, and fungi that live inside of our gastrointestinal tracts. We know that they play a role in many chronic diseases. When we chronically reduce the acid in our stomach, which is there for a purpose, and also which is there as a line of defense for our GI tract, then we leave the doors wide open for all kinds of other bacteria to get into the digestive tract. This can lead to an imbalance in the ecosystem which could potentially be a set up for all of these things that we are discussing here. That’s my theory. And it is certainly plausible and worth consideration.
So, what do we do? Suffer? Absolutely not! While nobody would argue that you avoid a PPI if you are in the hospital with a life threatening GI bleed from an ulcer, we certainly do not need to take these medications for a lifetime, outside of potentially reducing risk of Barrett’s esophagus (a precancerous change in the lining in the esophagus) from progressing to esophageal cancer and a few other special circumstances.
Here are a few initial tips:
- See if there are any medications you are taking that could be correlated with your reflux symptoms. Perhaps there could be an alternative if you identify something.
- Keep a food log or get food sensitivity testing to see if there are any foods that are triggers for you (it is not always tomato sauce or spicy foods; it could be bread!).
- Stop smoking
- Reduce alcohol consumption
- Don’t eat 2-3 hours before lying flat
- Avoid heavy, fatty meals (you should be doing this anyway!)
- Don’t over-eat (you shouldn’t be doing this anyway!)
- Make sure you talk to your doctor; it is possible you may need an upper endoscopy (EGD) or other evaluation to evaluate the esophagus and upper GI tract, especially if there are concerning symptoms like difficulty swallowing, pain with swallowing, and/or weight loss.
Lifestyle interventions are excellent ways to reduce acid reflux. Losing weight, eating healthier, exercising, modifying your habits and routine can all be great ways to improve your symptoms. Remember, your symptoms are probably happening for a reason. I have a few favorite natural treatments that I use to help control symptoms while working on the above. Make sure you consult a doctor who understands how to use these natural alternatives when trying to taper or wean off your PPI. Here are my top 3 natural alternatives for acid reflux treatment.
- DGL (Deglycyrrhizinated licorice). This is a mainstay in my practice. It comes in a variety of forms. Many people like the chewable DGL tablets but I am not so fond of the fillers and sugars that are in some of those formulations. I tend to prefer a pure powdered DGL. We want to make sure you don’t take a pure licorice for long period of time because doing that may have some important health consequences; however, taking DGL is different and safer than taking regular licorice. As always, be sure to discuss this with your doctor and make sure there are no interactions with other things you could be taking.
- Ginger. This is another favorite. Ginger has many health benefits. It can help reduce inflammation, improve arthritis symptoms, and fight certain infections. I love it as a natural treatment for nausea. It also works as a prokinetic which means it helps move things forward. It can help with stomach emptying, bloating, and constipation. So, it is a great adjunctive therapy for acid reflux.
- Slippery elm. This is another natural therapy that I use as an adjunct to the other therapies. It is particularly good for those that have upper throat and esophageal symptoms. It acts as a natural cooling blanket and helps coat the esophagus. I tend to prefer the lozenge form for minor esophageal symptoms.
While there may be a lack of definitive evidence correlating acid reflux medications with chronic health problems and diseases, there is definitely an ever-growing body of evidence hinting that there could be an association with PPIs and these conditions. My take on all this is that if there is no underlying major problem that could justify use of PPIs (most of the time there is not), we should do everything we can to minimize and eliminate their use and replace them with more natural therapies and lifestyle changes. This is what is best for us in the short term and in the long term!