HEALTH

Tronetti: Long-term antacid use can have adverse effects

Dr. Pamela Tronetti
For FLORIDA TODAY
Talk to a doctor before embarking on a long-term regimen of acid blockers and reducers.

I have been privileged to serve on Parrish Medical Center’s Pharmacy and Therapeutics committee. This keeps me up-to-date with the latest medications, even those used exclusively in the operating room or the emergency department.

But our last meeting sparked a lively discussion about a very common class of medications, PPIs (proton pump inhibitors). You know them as omeprazole (Prilosec, Zegerid), esomeprazole (Nexium), lansoprazole (Prevacid), rabeprazole (Aciphex), pantoprazole (Protonix) and dexlansoprazole (Dexilant, Kapidex).

Their job is to block the secretion of stomach acid by stopping the “proton pump” within the cells of the stomach lining. These life-saving drugs are often started during a hospital admission since they can prevent stress ulcers, which are common in critically ill patients. Other times they are prescribed for gastro-intestinal distress, and, of course, they are available over-the-counter.

But we are starting to realize that there are serious consequences when one disrupts the body’s natural production of stomach acid for a prolonged period of time. It totally changes the internal balance of the GI tract, affecting the absorption of nutrients and allowing bacteria to grow in what used to be a hostile environment.

There is an increased risk of hip fracture in people who have taken PPIs for a number of years. This is probably because the low-acid environment reduces the absorption of calcium carbonate by 40 percent. Calcium is necessary for bone growth and healing, and reduced intake is associated with osteoporosis. Luckily, calcium citrate is well absorbed in low-acid environments and is recommended for people who take PPIs.

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Magnesium deficiencies are seen with PPI use. Low magnesium causes symptoms like muscle pain and overall weakness. Levels need to be monitored in PPI users. Vitamin B12 absorption is also affected by this class of drugs. A low B12 level causes symptoms of depression, fatigue, memory loss, anemia and neuropathy.

Clostridium difficile (C. diff) colitis is a highly contagious infectious diarrhea. The use of PPIs doubles the incidence of C. diff, particularly in hospitalized patients. PPIs also interfere with the treatment of C. diff, reducing the cure rate by 50 percent and doubling the risk of recurrence.

Long-term use of these agents has been associated with increased risk of pneumonia. Normally, bacteria cannot survive in the stomach because of the acidic environment. But if there is no acid, swallowed bacteria can thrive in the stomach and esophagus. Severe reflux, choking or vomiting can bring the bacteria into the throat and upper respiratory tree where it can cause bronchitis and pneumonia.

A recent German study of people 75 and older reported that the use of PPIs increased the risk of dementia by 44 percent. However, this study was based on health insurance billing records, not an evaluation of live subjects. Another German study published at about the same time indicated that PPIs actually decreased the rate of developing dementia by 7 percent, so further investigation should be done to determine whether there is a real concern.

If you have been on PPIs for a long time, are unsure why you are taking them, or received them as preventive care during a hospital stay, talk to your doctor about whether they are still necessary. Often, these drugs can be decreased or discontinued. However, this may be easier said than done. Many people complain of a “rebound” of excess stomach acid production once the medication is stopped.

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Other choices include the H2 blockers. These decrease stomach acid production, but do not stop it completely. Common H2 blockers are ranitidine (Zantac), famotidine (Pepcid), nizatidine (Axid), and cimetidine (Tagamet). Overall, there is less of an association of the H2 blockers with pneumonia, C diff, osteoporosis and nutrient mal-absorption than the PPIs.

Over-the-counter antacids can be helpful, but shouldn’t be taken regularly without physician supervision, because they also interfere with acid-base balance and can alter the absorption of medications and nutrients.

An anti-reflux diet is a good option. It excludes certain foods like citrus, alcohol, carbonated beverages, onions, tomatoes, peppers, garlic, fried/fatty foods and regular (not decaf) coffee. Lifestyle changes like smoking cessation, weight loss and sitting upright for two hours after a meal can help relieve symptoms of acid reflux.

Talk to your doctor about your concerns and find the right course of treatment for you.

Dr. Pamela Tronetti is an osteopathic physician who specializes in geriatric medicine at Parrish Medical Center. Although she writes on a variety of topics, her practice is limited to senior citizens, particularly those with dementia.