July 6th, 2009
The real issue in PPI-induced acid rebound: Why are PPIs used in the first place?
A great deal of alarm has been voiced over a recent report that some patients with no previous acid-related dyspepsia or GERD developed acid symptoms after stopping PPI therapy in a month-long trial.
Should we really be surprised by this finding? Not really. PPI use is known to cause acid rebound, and the effect is thought to be related to PPI-induced gastrin secretion (secondary to an increase in gastric pH) and to gastrin’s effect on parietal cell mass expansion, which leads to increased acid secretion.
Should we be concerned that these drugs are being given to patients who have no acid-related symptoms? Absolutely. In my opinion, a PPI is warranted only if patient history indicates that gastrointestinal symptoms are likely acid related. These drugs should not be used for every abdominal discomfort or complaint.
The real take-home message from this study is not to stop taking PPIs, but rather to take a history and not to use PPIs (or for that matter any drug) unless we have a clear understanding of what we are trying to diagnose or treat.
What do you think?
13 Responses to “The real issue in PPI-induced acid rebound: Why are PPIs used in the first place?”
M. Brian Fennerty, MD
Editor-in-Chief
NEJM Journal Watch Gastroenterology
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In my opinion PPI medications should never be given without proper clinical judgement & indications. In my opinion Patients with no history of any acid related GI diseases need not be given PPI as prophylactic when they are prescribed with Aspirin or NSAID.
Absolutetly right. Many patients are on PPI without any valid reason. It is very important to take a good hsitory before prescribing any medicines.
We didn’t need a study on the first place to find this basic pathophysiologic premise! It was well known first the drug then followed, that means that “Science-Man” moved back.
All right now is a time to put things in proper perspective?
The variety of responses one gets from patients when asked how their PPI is working can be almost comical: “Doctor, it completely controls my constipation” or “I helps my bloating” or, worse, ‘My ENT started it three years ago for my cough but I can’t tell if it helps.” For years, PPIs have been what B12 injections were in the 50s, 60s and 70s: the safe – albeit more expensive – placebo for the masses, good for whatever ails you between the clavicles and the patellas, before we moved it further north into the pharynx and sinuses. Only recently has some of the shine come off of PPI “safety” with data about bone mineralization and interaction with clopidogrel.
In the US, medicine is, for the time being, still a service industry. We aim to please our costumers. The propensity of the (American) medical consumer to desire- often, demand- medical procedures, prescription and nonprescription drugs is a beautiful thing if you are in the business of medicine. Writing a prescription is a whole lot quicker than delivering a long explanation why it should not be written. “Antibiotics for your viral pharyngitis? You don’t need it, it won’t help, it could do you harm BUT since you INSIST…”
But for that seemingly rare patient with typical heartburn or erosive reflux esophagitis who never took a PPI, you can (if you are old enough) still experience the thrill of hearing the same phrase uttered by the first patient you started on Prilosec (actually, “Losec” when it was first released) oh so many years ago: “Doc, this drug is a miracle.”
Restrict the usage of PPIs, start high and taper down the dose before stopping the drug to avoid rebound acid hypersecretion
Many of my clients (I’m a psychologist) are physician-referred and have one or more medical conditions. I’ve been surprised at the large numbers who are getting a PPI and have not been counseled about nutrition or supplementation (related to potential malabsorption), nor have they been seriously counseled about risk reduction for GERD. Even as a non-physician, I can easily access published clinical-practice guidelines, so I wonder what are the obstacles for physicians being informed and convinced by same.
I am a patient who had been on PPI’s for roughly a year so I hope my experience shows how I got hooked on it. I’m in my 30’s and except for an occasional acid indigestion had not had any heartburn until last year when I went through a very stressful time and started having severe hurt burn. It was completely new to me so when it didn’t go away after a few painful weeks (although I discovered that Pepcid was helping) I went to see my doctor who put me on Reglan and prescription Zantac (which I know is an H2 blocker).
After 3 months, I was feeling a lot better but still had some mild discomfort when I went off the zantac so my doctor put me on Protonix for another two months (zantac at night, protonix during the day). During that time I was feeling GREAT. Even though by then I had altered my diet, exercised more to lose weight (I was about 20 pounds overweight), if on occasion I would drink carbonated drinks or ate spicy foods, I felt no discomfort while on those drugs.
So after the 2 months it seemed like it was a good idea to get off the Protonix (40 mg)and the zantac (300mg)(my prescription was finished anyway). Day 1 I felt pretty good, Day 2, I felt something was going on in my stomach and by day 3, I had the worst heartburn I had ever had and begged my doctor to refill my prescription so he wanted to see me.
I don’t have insurance so he thought an afforable and valuable tool would be to get an upper GI X-Ray which showed no damage, but that I did have reflux. And at this point my doctor referred to it as “chronic GERD”…the word Chronic scares me.
After that he pretty much gave me a year’s supply of Protonix and Zantac and told me to pick the one that worked better for me and just take one and of course, the Protonix worked better since when I tried to just go back to the Zantac alone (zantac is only $4 vs. $100 for the protonix), I would have to take more than one to even come close to not have pain so I went with the protonix alone and even that took a week to be enough by it self.
The doctor also told me to take a break from it every few months but every time I tried, the sudden acid rebound was just unbearable. Mostly because of money, I tried switching to Prilosec OTC ($20 vs. $100) and even though it wasn’t working as well initially, it worked better after a month (the side affects were not very good though making me be VERY regular) so when Pravacid 15mg became OTC, I tried it and it worked pretty well…again, it took a week to get used to it.
So that got me to thinking that perhaps, my condition is not chronic and I’m just not giving my self a chance to be weaned off the PPI’s and I did some google searches and found the study being discussed here and was shocked that my doctor didn’t tell me about acid rebound.
Since I do have reflux (or at least had it last year), I probably need to take a zantac now and then but my hope is to be back to normal. I’ve lost over 10 pounds, completely given up carbonated drinks, drink very very little alcohol and avoid spicy foods so I thought I could wean myself off the pravacid and started taking it every other day for a week. it wasn’t easy but I drank a lot of ant-acids.
For a week and a half now I’ve only taken zantac and no PPI’s and while it’s touch and go, it’s been getting easier every day. I hope I can be off the zantac in a month or so, but overall, I feel like I’ve been on an island with my self.
The doctor gave me the medicine to make the pain go away and not cause damage, but being 30something and taking pills for the rest of my life when I am mostly healthy just seems wrong and I wish more doctors have a way we can get off these drugs unless we absolutely need them.
My plan now is to see if I can survive with just the zantac for a month. If I still hurt then I don’t want to damage my esophagus so I will most likely see a GI specialist and see what they think. It just seems strange to me that I could go from healthy to needing to take a pill for the rest of my life in a period of a month.
For me, the nightmare with PPIs (rabaprozole) started 10 months ago, in July, when I went to see my doctor because of chest pain he diagnosed immediately as heartburn; also immediately, he handed me a prescription for the drug without mentioning anything about diet, lifestyle changes, etc. I was leaving on holidays the next day, so I did only a very quick check on the Internet and, reading the drug was safe, took it for a month. The hearburn having all but disappeared, I got off it after that month; I experienced acid rebound within days. Except that I had no idea it was rebound; in fact, I knew nothing about heartburn, Gerd, acid reflux, etc.
To make a long story short — I am much better educated today, and angry at my doctor about the fact that he handed me the prescription without even asking me about my diet, lifestyle, etc. Had he done so, we would have discovered together that the most likely cause of my heartburn was that I had started drinking a large diet coke everyday to help me handle the hunger pains I felt from dieting to lose weight (I had 60 pounds to lose, and had started a diet on May 1); we would have discovered also that I was doing other very stupid things, such as doing stomach crunches at the gym right after lunch or going for a bike ride right after supper — again, all in an effort to lose weight. But as I said, the doctor never discussed diet or lifestyle with me; just gave me the prescription.
This is the third time I’m trying to get off the medication and hopefully, this will be the last. I’ve learned about tapering off slowly; I’m also much wiser about my trigger foods, and I’ve implemented all the recommended lifestyle changes. Still, I had a major episode of heartburn just in the last two days, so I know I still have a thing or two to learn. The thing is, I’m doing it all on my own because my doctor thinks my concerns re: PPIs are ridiculous. In fact, he wanted me to double the dose from 20mg to 40mg; instead, I cut the dose first to 10mgs, then 5 mg, then nothing, and took out ALL dairy and soya milk out of my diet. That seems to have done the trick.
Ironically, the havoc to my system caused by acid rebound is what has helped me stick to my diet. Though I was more than ready and willing to have a bit of chocolate at Christmas, for instance, I didn’t even look at it because I knew it was one of the foods my stomach just couldn’t handle anymore. Same with all cakes and cookies, pizza, coffee, martinis, etc. I have lost 50 pounds since May 2009,and as summer is here and I’m doing a lot of biking and jogging, I don’t think it will be too difficult to lose the last 10. Still, I hope I can begin eating again at least some of the foods I’ve had to give up since being on the drug (note I never had problems with most of these foods before taking the drug, which to me seems to indicate that indeed, PPIs can trigger the very symptoms they’re supposed to eliminate). I am concerned about not getting the proper nutrients since cutting out all dairy, eggs, red meat,citrus fruit,various vegetables, etc. Plus, now that I’ve lost the weight, it would be nice to enjoy a few treats here and there. At this time, however, it’s simply impossible — unless, of course, I’m willing to stay up all night with painful burn feelings in chest and throat. Sometimes, it’s not that I’m willing; it’s just that each time I go through a few days of feeling good, I usually make a stupid mistake and eat something my stomach still isn’t able to handle at this point.
There’s another positive side to all this. And that is, that my eliminating dairy from my diet (that was a hard thing to do, and I did it in small stages: firt the milk itself, then yogurt, then cheese, then butter) I no longer suffer from post-nasal drip, which had been a major nuisance for years. I also used to have asthma-like symptoms, but that too is gone. So although I’m angry at my doctor for being so casual about prescribing PPIs, I cannot deny that some of the “side-effects” for me (losing practically all the weight, which is very hard to do when you’re menopausal; and the no longer having to deal with post-nasal drip and asthma because of having to cut out some of the foods I didn’t even know were a problem) have been extremely beneficial.
Still, I’ll keep on working at being off PPIs. It’s been 16 days so far; hopefully, there won’t be too many more episodes like the one I suffered in the past two days. During that time, it felt at times as if some invisible pumps were squirting pure acid into my stomach and up my esophagus. The pain was something awful and with it, of course, came lack of sleep and a general feeling of being unwell.
I entirely concur with the two patients above.
I am a relatively healthy woman, age 39, who went to the doctor six months ago due to chronic post nasal drip and occasional reflux that would become worse during a particularly grueling workout routine I’d been doing. I’d just lost 18 pounds through Weight Watchers.
Without any disgnostic testing, he prescribed omeprazole, gave me a list of foods I’d have to avoid for the rest of my life, told me to elevate my bed, and sent me on my way. I had no idea it would turn into the nightmare it’s now become for me, which apparently I’m going to have to deal with for the rest of my life.
The omeprazole began causing severe lower GI issues. I was going to the bathroom seven or eight times a day and my stomach was super gassy. When I asked the doctor if the omeprazole might be causing lower intestinal issues, he was skeptical and, dare I say, insulted that I’d questioned his diagnosis of IBS. He ended up sending me to a GI specialist, though, because I’d lost about ten pounds over my previous weight loss goal.
In the interim, I took myself off the omeprazole because I couldn’t handle the side effects any longer. Of course, that’s when the intense burning reflux began. I couldn’t even have a sip of water or a bite of toast without being in real misery, and the psychological stress was also unbearable. I’m surprised my husband didn’t up and leave me because of my constant complaining and emotional pleas for ideas to relieve the symptoms outside of that pernicious prescription.
When I finally got in to see the GI, he told me that my lower intestinal distress was very likely due to a food parasite, and that it would eventually go away. I told him about my going off the medication and that I thought perhaps I was having acid rebound – something I came across on the internet. He honestly looked at me with as if he’d never heard of such a thing. He gave me the same sheet of do’s and don’t’s that the other doctor gave me, and he gave me a list of other medications I could try if I wanted to.
About this time, I started seeing an acupuncturist who recommended chewable papaya enzyme tablets. They worked great; however, I was having to chew them every time I ate. I was also concerned that the acid might be causing problems at night, even though I don’t eat two hours before bedtime. Who can tell?
Long story short: I not only had to go back on the omeprazole, but I now have to take two pills a day, instead of just one. The lower GI problems are still with me six months later, in various forms and I’m looking down the barrel of what appears to be a life time of taking medicine that I’m learning more and more (through personal initiative) can cause real problems down the road.
I’m trying to see things from the doctor’s perspective. I’m sure it’s a real pain to have self-diagnosing patients who watch too much Dr. Oz and are mistrustful of doctors. However, from where I stand, I’m damned concerned. I’m the one living with the symptoms. When I went in for that first visit, I was experiencing some mild discomfort. Now I’m way worse than when I first walked through those doors. I’d much rather have suffered a little back then than wrestle with the plague of exacerbations and side effects I have to deal with now.
I found your post when carrying out research for my own blog on heartburn. I was wanting to provide my readers with details of the potential side effects of using PPIs and was surprised by how many articles that I found on the Internet that don’t even mention rebound acid hypersecretion.
Having read the other comments it seems very strange that the FDA has not acted before to put warnings about this potential side effect on the boxes of these these drugs. At least Public Citizen is now actively campaigning on this issue.
I just came across this site and I am living the nightmare. It all started about 3 years ago with what they thought was a pancreatic attack or ulcer. I had pigged out on pizza, and was curled up in the fetal position on the floor for the next 6 hours I couldnt move. By the time I got to the clinic the next day it had eased a little, and they could find nothing in my blood work xray or ekg wrong. they said it was prob h pylori because they did a blood test and it was positive.
So they put me on prilosec and some antibiotics for a few weeks. Great but a month later the pain returned, this wasnt a burning pain at all it was a deep boring pain in my upper right side going through to the back. Got sent to a GI, ultrasound on gallbladder and pancreas negative, hida scans first one was 57% second was 80 % told within normal. EGD scope and colonoscopy normal cept for a small hiatal hernia, and some spots in my colon from UC that I always had.
GI thinks functional abdo pain w/e that means and gerd, even though I dont show any gerd damage. So onto ppi’s i go, and been on them for the last 3 years every day. I have not gotten better but sicker, I am now fatigued all the time, my abdomen is distended I look like a beach ball and its hard. I go to the bathroom a lot more than ever before, and its a yellow color doc says its malabsorbtion now. I have a squeezing pain now in my esophagus, my joints hurt and I get dizzy a lot.
Long story short I just feel ill all around and have a good amount of pain. Cant get off the ppi’s the rebound is horrible and painful. I am so mad because this all started from a guess on the doctors part. Lets try a pii and see what happens…this is what happens. I am far more ill now than I ever was before taking this drug, and the symptoms I went to the doc for in the first place are still there also. Please doctors I beg you dont just toss these things out like candy to your patients. They have very real long term effects, and become an addiction for the body after taking them a little while.
Omneprazole should be banned. The directions that come with the box you buy over the counter do not tell you that it leaches calcium out of bones and prevents absorbtion of vitamin B12 and C. This is drug company chicanery. They do say not to take it long term but offer no explanation of this – so people do not take it seriously. I have been off it for 2 days and feel horribly nauseous – so I checked online and found that thousands of other people who tried to quit have experienced acid rebound.
I went to my GP combining of lump in the throat. She told me it was “probably” GERD. So she prescribed Protonix. I took it for a while and I wasn’t feeling the lump anymore so I stopped. No problems. A few months ago I developed yellow bowel movements. GP told me to take the protonix again. Bowel problems resolved but I kept taking the protonix for two months. Then I figured I was safe to stop and did so. So two days into stopping I am on FIRE. I never had this burning before. Only the lump feeling. Now I am going through hell trying to get off this med. Taking OTC Zantac and baking soda in water. Chewing gum and bought some DGL licorice today. I am praying that this will resolve soon. I can’t take much more of this burning in my throat and chest.