Some of you will simultaneously reach for a hot dog and for your heartburn medication this 4th of July. You may be shocked to know that both can increase your risk of a heart attack.
A study published in June in journal PLOS ONE showed that the powerful acid-blocking medications called proton pump inhibitors (PPIs) were associated with a two-fold higher risk of cardiovascular death. Earlier studies revealed an increased risk of death for people taking the blood thinner Plavix with a PPI, but this new study showed the higher death rate for all. There’s also evidence that PPIs increase the risk of community acquired pneumonia, anemia, and osteoporosis. With 21 million people in the US currently using PPIs, the public health implications are staggering.
These powerful acid blockers are popular, with over $13 billion in sales, because they work. Over the counter PPIs include omeprazole (Prilosec) and lansoprazole (Prevacid); several more are available by prescription. They are potent medications and can be of great help to people diagnosed with stomach ulcers or irritation (gastritis or esophagitis) while they heal. But they were never intended to be used long term. Indeed, the current recommendation is for 4-8 weeks of use.
One problem is that doctors aren’t prescribing them that way. Another is that the drug creates a physical dependence. A well-known side effect is an extremely uncomfortable rebound of stomach acid production and heartburn—in other words, acid-blockers can cause the very problem they are supposed to treat. A 2009 study (registration required) revealed that young healthy volunteers with no previous symptoms of heartburn had severe reflux when they attempted to stop taking the drug. Which means that once a person is taking these drugs for as short as 4-8 weeks, they can be incredibly hard to get off of.
As an integrative medicine physician, I often see patients who want help discontinuing PPIs. They have repeatedly attempted to stop but horrific heartburn drives them right back onto the drug. One of my patients had been on the drug for years and felt great, but she was worried about the potential side effects. The first time she tried going off, she only lasted four days. And her digestive system was out of whack for two weeks.
To help patients like her, integrative medicine practitioners work with their patients to discover and eliminate the underlying reasons for the heartburn, which can include particular foods, stress, and obesity. We might suggest a trial off of dairy, gluten, coffee, chocolate, fried foods, or alcohol. For stress, we suggest breathing practices, guided imagery, yoga or another centering practice. We work together to manage weight. If a person is trying to wean off a PPI, we substitute supplements and weaker medications, which reduces the rebound acidity.
Despite the evidence, the American Gastroenterological Association position paper on managing reflux, minimizes the risk of long term PPI use. Instead it focuses on the common recurrence of symptoms when patients attempt to discontinue.
As a nation, we put a lot faith in pharmaceuticals. According to the Mayo clinic, 70% of Americans take one prescribed medication and 50% take two. A full 20% of are on five or more medications. It is often easier to pop a pill than to say no to that yummy fried food that you know gives you heartburn.As an educated consumer, ask your doctor or pharmacist how long you will need to take a prescribed medication and how hard it will be to get off.
Even if you ask all the right questions, however, it often takes years before we discover unexpected side effects. Vioxx, a nonsteroidal anti-inflammatory drug (NSAID), is the classic example. Released by Merck in 1999, it was recalled in 2004, after studies linked it to 38,000 cardiovascular deaths. An insulin sensitizing drug called Rezulin was recalled by the FDA in 2000 when it was found to cause liver damage and its sister drug Avandia increased the risk of heart attacks by 40%. The number of excess deaths due to acid blockers has yet to be calculated.
Medications can be lifesavers. Beginning with the introduction of antibiotics in the 1940s, to the humble use of aspirin to prevent heart attacks, to the recent advances in chemotherapy, our longevity is partly related to pharmaceutical innovations. At the same time, many experts believe this generation will be the first to have a shorter life expectancy than their parents. This is not due to a lack of available drugs, rather it’s because we don’t want to fully address lifestyle-related diseases with lifestyle change.
Let’s applaud medications as the lifesavers they can be and tackle the root causes of diseases like diabetes, high blood pressure, and heart disease with health promotion. Heartburn is a classic disease of lifestyle. The first-line treatment—and often the only treatment needed—is a change in diet and better stress management.
So enjoy that hot dog on the 4th, and then get off your PPI. It might help you live longer.