- Dr. Mike Purdon
Goodbye PPI: How to Break Up With Your Heartburn Pill
Please don’t make any changes in any of your medications until you have carefully reviewed this topic with your family doctor.
It is always better to take fewer prescription medications, but it may seem odd that we have recommended that you try to stop your proton pump inhibitor (PPI) or stomach acid suppression pill. These medications can be great for reducing stomach acid and helping reduce abdominal pain, but there are risks associated with taking them for long periods of time. We hope that this article might be helpful in explaining why we think you should consider reducing or stopping these pills and there are some tips on how to come off them successfully.
First, let’s review which medications we are talking about. Proton pump inhibitors, or PPI’s, are a powerful class of medication which suppress or eliminate the acid in your stomach. I like how the Harvard Health Letter puts it:
Stomach acid is natural, a valuable chemical contributor to orderly digestion. But in excess or in the wrong place, it's a menace, inflaming and irritating the esophagus, typically causing heartburn and sometimes contributing to the development of ulcers in the stomach and the duodenum, the first part of the small intestine. Reducing stomach acid levels isn't one of medicine's glamour jobs, but it's yeoman's work, so PPIs are generally considered quite a success story: safe (more on that just below), effective medications that target the source of a lot of gastrointestinal distress.
Some examples of PPI’s include omeprazole (Losec), esomeprazole (Nexium), lansoprazole (Prevacid), pantoprazole (Pantoloc), rabeprazole (Pariet) and dexlansoprazole (Dexilant). These medications are available by prescription and some are available over the counter in the pharmacy. These drugs are used to treat several conditions that can cause abdominal or chest pain including heartburn, gastroesophageal reflux (GERD), ulcer disease and inflammation of the lining of the stomach (gastritis). These pills are also sometimes prescribed to prevent complications that can occur with the use of other medications such as anti-inflammatory drugs and blood thinners.
Some people need to take these medications indefinitely and PPI’s are considered safe when we carefully consider the risks and the benefits of long term use for these conditions. Some examples of conditions that require long term use include:
Prior bleeding from the stomach, small intestine or esophagus,
Barrett’s esophagus: a condition in which tissue that is similar to the lining of your intestine replaces the tissue lining your esophagus. This condition is identified at the time of a scope and people with Barrett's esophagus may develop a cancer called esophageal adenocarcinoma and lowering acid can reduce this risk.
Severe esophagitis, or inflammation of the esophagus.
Ongoing NSAID or anti-inflammatory use in patients at high risk of bleeding.
Please don’t make any changes in your medications until you have confirmed with your doctor that you do not have any of these conditions.
You probably can tell by now that PPI’s are also prescribed for a lot of other conditions as well and long term use isn’t considered as safe in treating these disorders. Some examples include:
Gastroesophageal reflux (GERD)
“Silent heartburn” associated with runny nose, cough, asthma, voice change, etc.
We know that PPI’s can really help with symptoms associated with these conditions, but Choosing Wisely puts it nicely:
In most cases, you don’t need a PPI for heartburn. You can get relief from a less powerful drug. And when you do need a PPI, you should take the lowest dose for as short a time as possible.
Most experts agree that you should not take these drugs for more than eight weeks at a time. Here’s why: PPI’s can cause a lot of side effects over the long run. These may include:
Infections in the intestines. (Clostridium. difficile, Campylobacter, Salmonella)
Fractures of the bones.
Low magnesium levels that can cause cramps and pain.
A kidney injury called acute interstitial nephritis.
Vitamin B12 deficiency. This vitamin is critical for the health of your blood cells and nerve tissue.
So if you are reading this because we encouraged you to stop your PPI we think that there is more risk than benefit if you keep taking them long term. Let’s review how you can stop these medications successfully. If you have taken PPI’s for several months or more, it is quite possible that you may experience rebound acid secretion and your symptoms may get worse for up to two weeks when you stop your PPI. This can easily be misinterpreted as a need for ongoing therapy. For this reason, we often recommend that you taper the PPI over time. We can do this by decreasing the PPI dose by 50% for a few weeks before stopping altogether, or by increasing the interval between doses to every 2 or more days before stopping.
Sometimes, it works just as well to start using the medication “on demand.” To do this, you simply take the medication until the symptoms get better and then you stop. Other people decide to use the medication on only two or three days of the week to control their symptoms.
Of course, while you are stopping these medications it is really important to also focus on all the other ways we can reduce heartburn such as:
Elevating the head of the bed
Eating smaller meals
Using non PPI, over the counter antacids occasionally
Avoiding foods and drinks that trigger heartburn
The Mayo Clinic has a nice review of home remedies for heartburn here.
We hope that this article helps explain why we think that you should stop your PPI and how to do it successfully. For patients who want more detailed information on this topic, here is a good resource:
Deprescribing Proton Pump Inhibitors: Evidence Based Clinical Practice Guideline