Weighing the Benefits of PPIs

Proton pump inhibitors (PPIs) suppress stomach acid and are amongst the most commonly prescribed drugs in the world, racking up billions of dollars a year for the pharmaceutical giants who market them aggressively to physicians and consumers. It’s hard to leave your doctor’s office – especially if your doctor is a gastroenterologist – without a prescription for one if your complaint is even remotely gastrointestinal in nature: heartburn, abdominal pain, bloating, gas, belching, nausea, bad breath, are some of the common reasons they’re prescribed; but hoarseness, sore throat, a chronic cough, non-cardiac chest pain, and even sinus symptoms are frequently attributed to “silent reflux” and treated with long-term acid suppression.

For decades, one of the strongest indications for a PPI has been the diagnosis of Barrett’s esophagus (BE), a change in the lining of the esophagus that occurs in about 10% of people with chronic acid reflux. Less than 1% of people diagnosed with Barrett’s will go on to develop esophageal cancer, but the equation for gastroenterologists has long been BE = lifelong PPI.

Conservative estimates suggest 20 to 75% of PPI prescriptions are unnecessary, and reflux can almost always be treated successfully with lifestyle modifications like cutting back on caffeine, alcohol, high-fat food, portion size, and late night eating. But perhaps an even bigger question than whether they’re necessary is whether they work in the people who need them most – PPIs have never actually been clearly proven to prevent esophageal cancer in people with BE.

A recent review and meta-analysis by the Divisions of Gastroenterology at Shanghai Jiao Tong University and Johns Hopkins University set out to answer that precise question, analyzing data from over 5000 patients with BE. Shockingly, they found no association between the use of PPIs and a reduction in the risk of esophageal cancer (or a pre-cancerous state called high grade dysplasia) in patients with BE. They concluded PPIs had no cancer-protective effects, despite the fact that current clinical guidelines and practices still recommend long-term PPIs in both symptomatic and asymptomatic patients with BE.

Of additional concern is the fact that these drugs, like all drugs, come with side effects: a potential increased risk of kidney disease, dementia, bone fracture, heart attacks, bacterial overgrowth, pneumonia, infections and even some forms of gastrointestinal cancer. If you’ve been prescribed a PPI (or any medication), it may be time to start asking your doctor some important questions: What is the scientific data supporting the use of this drug? What would happen if I didn’t take it? What are the non-pharmaceutical treatment options?

Changing your diet and lifestyle are hard, but they come with the added benefit of improving your overall health, and none of the hazards of a dubious pharmaceutical fix.

By: Dr. Robynne Chutkan