More Bad News for Acid-Blocking Medications
Every day, millions and millions of people take acid blocking medications to treat the symptoms of acid reflux, for duodenal ulcers and as an important part of a treatment strategy to kill the H. pylori infection. The US FDA approved these medications, which include such popular brands as Prilosec, Protonix and Zantac, for short-term. However, people often end up taking these medications long-term—for many years—despite the fact that the FDA never approved them for longer than a couple of months.
While these medications, like many medications, are effective at treating the symptoms of disease, often they don’t treat the underlying cause and they can create deadly consequences.
There are two classes of acid-blocking medications, proton pump inhibitors (PPIs) and histamine-2 receptor antagonists (“H2 blockers”). PPIs include Prilosec, Nexium, Prevacid. H2 blockers include Zantac, Prilosec and Tagamet.
The case against using acid-blocking medications long-term keeps growing. A 2018 study published in the journal Gut concluded that these drugs increase people’s risk of stomach cancer. The researchers followed 63,397 patients for 7.6 years who had been prescribed long-term acid-blocking therapy.
Using PPIs was associated with an increased gastric cancer risk, while H2 blockers were not. The longer someone used PPIs, the greater their risk. After just one year the risk was 500% greater than people not taking acid blocking medications, a danger that increased by 834%.
In a second study, published in JAMA Neurology in 2016, acid-blocking medications were associated with increasing dementia risk. The German study evaluated medical records of 73,679 people ages 75 and older. Researchers found that regular PPI use increased dementia risk 44% compared with those not using the drugs. While more research still needs to be done on this issue to understand if there is a direct cause-and-effect relationship in humans, mice fed PPIs experienced an accumulation of beta-amyloid plaque in their brains. This unhealthy protein is known to be a major contributing factor in the development of dementia.
Both PPIs and H2 blockers have also been shown to increase hip fracture risk in people with osteoporosis. In 2010 the Journal of the American Medical Association (JAMA) reported that the risk of hip fracture increases by 22% after one year and nearly 60% after four years.
This story of medications causing dangerous, sometimes fatal side effects is not new. Another JAMA study in 1998 concluded that fatal drug reactions for hospital patients “appear to be between the fourth and sixth leading cause of death,” and that the rate of fatal drug reactions had been stable for the past 30 years, killing more than 100,000 people annually. While medications can be extremely helpful, and indeed life-saving, the data are clear, medications can be very dangerous as well. One has to always balance out the potential risks with the potential benefits, and that discussion should always be between you and your healthcare provider.
It’s not even that pharmaceuticals per se are the culprit, but it’s the underlying paradigm in medicine that could use some work. The current philosophy underlying medicine today is that diagnoses are based primarily on symptoms and mostly treated with medications to simply suppress the symptoms instead of identifying and treating the underlying causes of disease. For example, the current conventional approach to acid reflux is to simply assume that the stomach is producing too much acid and to suppress the acid production with PPIs or H2 blockers. But this ignores the fundamental physiology of the body and doesn’t address the underlying causes of why people are actually experiencing acid reflux.
The Important Role of Stomach Acid
Digestion involves the breakdown of large molecules into smaller, readily absorbed molecules. While some digestion begins with the production of enzymes in the mouth, the stomach is where the process of digestion really gets underway. Cells in the stomach excrete specific enzymes to break apart fats, starches, and proteins. The enzymes, however, are inactive and must be activated by stomach acid.
When someone produces enough stomach acid, proper digestion in the stomach occurs. But many people don’t produce enough stomach acid. Low stomach acid production is called hypochlorhydria, and when no stomach acid is produced it’s called achlorhydria. Decreased stomach acid production occurs from aging, caffeine, overeating, stress, medications (especially those that block the production or excretion of stomach acid such as Protonix, Tagamet, Pepcid, Axid, Zantac, Prevacid, Prilosec, Aciphex, Nexium), alcohol, and stomach surgeries that destroy the acid-producing cells.
Many people produce less stomach acid as they age, and it’s been estimated that 10–21% of people sixty to sixty-nine years old, 31% of those seventy to seventy-nine years old, and 37% of those above the age of eighty have hypochlorhydria or achlorhydria, and this rate may be higher in people with autoimmune conditions.
One question that could be posed to patients to screen for their risk of low stomach acid is, “Do you feel fuller sooner than you used to and stay full longer than you used to when you eat?” If the answer is yes, it may be that they have low stomach acid since decreased stomach acid increases the amount of time food sits in the stomach before passing into the small intestines.
When stomach acid is low, vitamins and minerals may not be efficiently released from the food that contains them. This may result in decreased availability of nutrients for absorption and nutritional deficiencies. People with low stomach acid have been shown to be at increased risk for vitamin and mineral deficiencies. For example, low stomach acid is a known risk for iron deficiency.
Symptoms of low stomach acid production include bloating or distension after eating, diarrhea or constipation, flatulence after a meal, hair loss in women, heartburn, indigestion, malaise, and prolonged sense of fullness after eating.
Stomach acid plays two other important roles. It acts to sterilize food and signals the lower esophageal sphincter (the muscle separating the esophagus from the stomach) to close. The gut normally contains about four hundred different species of bacteria, which are required for normal digestion and absorption of nutrients.
It has been estimated that there are more bacterial cells in the gut than all the cells in the body combined. These beneficial bacteria are required for normal digestion and absorption of nutrients. When inadequate sterilization of food occurs, however, pathogenic (bad) bacteria, viruses, and fungi can pass into the small intestines. This disrupts the healthy ecology in the gut and alters the delicate balance between healthy and unhealthy microbes.
This imbalance in intestinal flora is called dysbiosis, and it can occur with the overgrowth of pathogenic bacteria and/or fungus. Symptoms of intestinal dysbiosis include abdominal gas and bloating, post-nasal drip, “brain fog” (feeling like you’re just not mentally sharp), and sugar cravings. Abdominal gas and bloating are caused by fermentation of food by the bacteria and fungus, which causes the production of gas, such as methane. Post-nasal drip is caused by immune system activation by bacteria and fungi. Sugar is the preferred energy source for the fungi, which can lead to sugar cravings. Bacteria and fungi secrete their own waste products, such as ammonia, that can enter the blood stream, cross into the brain, and cause brain fog. Additionally, intestinal bacterial overgrowth is now understood to be a risk factor for developing gastroesophageal reflux disorder (GERD).
When low stomach acid production decreases the ability of the lower esophageal sphincter to close, the result is that the acid produced in the stomach can reflux up into the esophagus and cause symptoms of GERD. The typical medical response to gastric reflux, which can cause burning, coughing, and asthma-like symptoms, is to prescribe acid-blocking medications. However, the actual cause in many people is too little acid and not too much acid. Stomach acid production can also be tested by using a meter, called a Heidelburg pH capsule test.
Low stomach acid can also occur in from infections, such as Helicobacter pylori (H. pylori) in the stomach. And treating this infection can correct the underlying problem and improve GERD symptoms.
When people have low stomach acid, some doctors may also provide hydrochloric acid capsules for people to take with meals that help improve their digestion and eliminate GERD. There are some instances when people should not supplement with acid pills, and it’s important to only pursue this option while working with a healthcare provider.
Taking time to understand the underlying possible causes and then working to correct them is a more rational approach to helping people than simply prescribing more and more medications. Doing so could not only help people improve their health, but also avoid dangerous drug side effects.
Baik HW, Russell RM. Vitamin B12 deficiency in the elderly. Annu Rev Nutr. 1999;19:357-377. [Article]
Bengmark S. Ecological control of the gastrointestinal tract. The role of probiotic flora. Gut. 1998;42(1):2-7. [Article]
Lord R, Braley JA, eds. Laboratory Evaluations for Integrative and Functional Medicine. 2nd ed. Duluth: Metametrix Institute; 2008. [Book]
Cheung KS, Chan EW, Wong AYS, Chen L, Wong ICK, Leung WK. Long-term proton pump inhibitors and risk of gastric cancer development after treatment for Helicobacter pylori: a population-based study. Gut. 2018;67(1):28-35. [Article]
Gomm W, von Holt K, Thomé F, et al. Association of proton pump inhibitors with risk of dementia: A pharmacoepidemiological claims data analysis. JAMA Neurology. 2016;73(4):410-416. [Article]
Guarner F, Malagelada J-R. Gut flora in health and disease. The Lancet. 2003;361(9356):512-519. [Article]
Hongo M, Ishimori A, Nagasaki A, Sato T. Effect of duodenal acidification on the lower esophageal sphincter pressure in the dog with special reference to related gastrointestinal hormones. Tohoku J Exp Med. 1980;131(3):215-219. [Article]
Hurwitz A, Brady DA, Schaal SE, Samloff IM, Dedon J, Ruhl CE. Gastric acidity in older adults. JAMA. 1997;278(8):659-662. [Article]
Kassarjian Z, Russell RM. Hypochlorhydria: A Factor in Nutrition. Annual Review of Nutrition. 1989;9(1):271-285. [Article]
Kelly GS. Hydrochloric Acid: Physiological Functions and Clinical Implications. Alt Med Rev. 1997;2(2):116-127. [Article]
Lazarou J, Pomeranz BH, Corey PN. Incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies. Jama. 1998;279(15):1200-1205. [Article]
Martinsen TC, Bergh K, Waldum HL. Gastric juice: a barrier against infectious diseases. Basic Clin Pharmacol Toxicol. 2005;96(2):94-102. [Article]
Prousky JE. Cobalamin deficiency in elderly patients. CMAJ. 2005;172(4):450-451. [Article]
Sharp GS. The diagnosis and treatment of achlorhydria; preliminary report of new simplified methods. West J Surg Obstet Gynecol. 1953;61(7):353-360. [Article]
Simon GL, Gorbach SL. Intestinal flora in health and disease. Gastroenterology. 1984;86(1):174-193. [Article]
Sturniolo GC, Montino MC, Rossetto L, et al. Inhibition of gastric acid secretion reduces zinc absorption in man. J Am Coll Nutr. 1991;10(4):372-375. [Article]
Tomohiko S, Masaki I, Nobue H, Yoko H, Masuo N, Susumu T. Gastric Acid Normosecretion Is Not Essential in the Pathogenesis of Mild Erosive Gastroesophageal Reflux Disease in Relation to Helicobacter pylori Status. Digestive Diseases and Sciences. 2004;V49(5):787-794. [Article]
Urita Y, Sugimoto M, Hike K, et al. High incidence of fermentation in the digestive tract in patients with reflux oesophagitis. Eur J Gastroenterol Hepatol. 2006;18(5):531-535. [Article]
Wood RJ, Suter PM, Russell RM. Mineral requirements of elderly people. Am J Clin Nutr. 1995;62(3):493-505. [Article]
Wright JV. Dr. Wright’s Guide to Healing with Nutrition. New Canaan, CT: Keats Publishing; 1990. [Book]
Yang YX, Lewis JD, Epstein S, Metz DC. Long-term proton pump inhibitor therapy and risk of hip fracture. JAMA. 2006;296(24):2947-2953. [Article]
Article at-a-glance: When it comes to health, we’re our own worst enemies, but these 5 tips can help you become your health's best friend. Negative thoughts are goal killers. If you want to behave differently, you have to think differently. Procrastination steals your...
Article at-a-glance: The thyroid gland is sometimes called the “master gland.” When the thyroid isn’t working well, it can create symptoms throughout the body. Since symptoms can be wildly different in different people, ranging from headaches and brain fog to...
November is the month of gratitude because it's Thanksgiving and people are focused on being thankful for all the wonderful things in their lives. But there are powerful arguments why it's important to be thankful, and practice gratitude year-round. Multiple studies...