Should reflux medication be taken long-term?

Proton pump inhibitors, or PPIs, are up there with statins (cholesterol drugs) as the most prescribed medications in Australia, the UK and USA. In Australia last year, 10,389,022 prescriptions were dispensed for pantoprazole (Somac) and 8,422,704 prescriptions for esomeprazole (Nexium or Nexium 24HR).

I've been meaning to write about reflux for a while, but an article in the Sun-Herald last weekend spurred me into action ('Common medicines face class action'). To summarise, lawyers in Australia are investigating a possible class action against the pharmaceutical companies that produce the popular drugs Nexium (esomeprazole), Losec (omeprazole), Somac (pantoprazole), Pariet (rabeprazole) and Zoton FasTabs (lansoprazole) due to claims that these drugs are linked with stomach cancer and kidney failure. A similar class action occurred in America last year with AstraZeneca (the maker of Nexium and Nexium 24HR) facing 11,000 lawsuits over kidney damage caused by reflux drugs.

Reflux is a common condition, particularly among adults over 40, with a higher prevalence in elderly women due to factors such as post-menopausal hormonal changes, reduced oesophageal motility, delayed gastric emptying, and multiple medication use. Lifestyle factors like a high-fat diet, obesity, smoking and alcohol also contribute.

What many people don’t realise is that PPIs are meant for short-term use. According to the Royal Australian College of General Practitioners (RACGP), "PPIs are generally well tolerated; however, use beyond eight weeks is rarely indicated and increases the risk of adverse events." Long-term PPI use is only recommended for specific conditions like Barrett’s oesophagus, Zollinger-Ellison syndrome, severe erosive disease, peptic stricture, or a history of bleeding gastric ulcers.

Another thing that is not commonly known is that taking a PPI long-term can actually make reflux worse due to the medication causing stomach acid levels to drop too low. The reduced stomach acid can lead to poor digestion and delayed gastric emptying, ultimately causing food and acid to back up into the oesophagus.

Other adverse effects of long-term PPI use include:

• Deficiencies in essential nutrients (e.g. magnesium, calcium, vitamin B12 and iron) due to reduced absorption.

These deficiencies can lead to an increased risk of osteoporosis and bone fractures, anaemia, neurological disorders, muscle cramps and weakness, immune system impairment, depression and mood disorders, and cardiovascular problems.

• Increased risk of infections and SIBO

Reduced stomach acid can impair the body's defence against harmful pathogens, resulting in a higher susceptibility to viral, parasitic and bacterial infections, for example, Clostridium difficile. Low stomach acid also increases the risk of Small Intestinal Bacterial Overgrowth (SIBO), while SIBO can exacerbate reflux symptoms, resulting in patients ending up in a vicious cycle.

• Impaired digestion and absorption of protein,

Impaired digestion of protein can contribute to many conditions, including: muscle wasting and sarcopenia (particularly in older adults); immune system dysfunction; delayed wound healing; hair, skin and nail problems; hormonal imbalances; cognitive impairment; and fatigue and weakness.

Whilst I’m not opposed to medication, it concerns me that many GPs and specialists prescribe PPIs on a long-term basis without attempting to investigate the underlying cause of a patient's reflux. I’ve lost count of the number of clients I’ve seen who are on some type of PPI, with the age of these clients ranging from women in their 70s to as young as teenagers. Several of them have been on PPIs for so long that they can't even remember when they first started taking them!

If you experience mild or intermittent reflux and have been taking a PPI long-term, you may wish to speak to your doctor about alternative measures for managing your symptoms.

Note: It is important to taper off PPI medications to prevent rebound acid hypersecretion (which can cause symptoms to worsen if the medication is stopped abruptly), so your doctor may suggest that you take an antacid medication, such as Gaviscon. Antacids are generally a safer alternative to PPIs and are not associated with as many adverse effects.

Remember: reflux medications make the pharmaceutical companies A LOT of money so it is in their best interest that patients continue to simply focus on treating their symptoms, rather than addressing the cause. These drugs are also subsidised by the government, which makes them a cheap and appealing option for patients.

Unfortunately, long-term use of PPI medication commonly leads to other health problems down the line, and often results in patients having to take a whole load more medications!

On a more positive note, reflux can be treated effectively without medication and I have had success doing so with my clients.

The process I use addresses three different issues - identifying and eliminating reflux triggers, healing the gut lining and establishing a healthy gut microbiome, and supporting optimal digestion.

Identifying and eliminating reflux triggers 

• Foods: common trigger foods for reflux include spicy foods, fatty or fried foods, chocolate, peppermint, citrus fruits, tomatoes, garlic, onions, and caffeinated or carbonated beverages)

  Food triggers can be very individual so I always recommend keeping a food and symptom diary for at least two weeks. Making a note of everything you eat and drink and when you experience reflux symptoms can be very helpful in working out your specific food triggers. This is how one of my clients discovered that her trigger was green tea!

• Alcohol and smoking: both can relax the lower oesophageal sphincter, allowing stomach acid to flow back into the oesophagus.

• Large meals and eating late at night: overeating or lying down soon after eating can increase the risk of reflux.

• Obesity: Excess weight can put pressure on the stomach, pushing acid up into the oesophagus.

• Medications: Certain medications, such as NSAIDs (e.g. ibuprofen, diclofenac), calcium channel blockers, sedatives, and some antidepressants, can relax the lower oesophageal sphincter or irritate the oesophagus.

• Stress: Stress and anxiety can increase stomach acid production and lead to reflux.

Healing the gut lining and establishing a healthy gut microbiome

There is a common misperception that when we talk about “the gut” we are referring to our stomach. The gut actually refers to the entire gastrointestinal tract - from our mouth to our anus. As our oesophagus is part of our gut, and is often inflamed in people with reflux, it is important to work on healing the gut lining and repairing the intestinal barrier, as well as establish a healthy gut microbiome. 

Dietary strategies for gut healing:

• Bone broth: bone broth is rich in collagen, gelatin, and amino acids (like glutamine and glycine), which help to repair and regenerate the gut lining.

• Fermented foods: Foods like sauerkraut, kimchi, kefir, yogurt and miso provide probiotics that help maintain a balanced gut microbiome and support gut barrier function.

• High-fibre foods: Soluble fibre from foods like oats, chia seeds, flaxseeds, apples and sweet potatoes feed beneficial gut bacteria, promoting the production of short-chain fatty acids (like butyrate), which are essential for a healthy gut lining.

• Leafy greens and colourful vegetables: these foods provide antioxidants, fibre and essential nutrients that reduce inflammation and promote a healthy gut environment.

• Healthy fats: Omega-3 fatty acids (found in fatty fish, flaxseed, chia seeds and walnuts) and monounsaturated fats (found in avocados and olive oil) have anti-inflammatory properties that support gut health.

Nutritional supplements that can be helpful for gut healing:

• Glutamine

• Zinc

• Prebiotics, e.g. partially hydrolysed guar gum (PHGG)

• Fish oil or algae oil

• Probiotics

• Aloe vera

• Vitamin D

• Quercetin

• Curcumin

Strategies to support optimal digestion

• eating smaller, more frequent meals to avoid overfilling the stomach

• eating slowly and chewing food thoroughly to aid digestion and reduce pressure on the lower oesophageal sphincter.

• incorporating high-fibre foods and easily digestible proteins to improve gut motility and prevent constipation.

• supplementing with digestive enzymes can help break down carbohydrates, proteins, fats, and lactose more efficiently. This reduces the likelihood of undigested food lingering in the stomach, which can contribute to reflux.

Other strategies to manage reflux symptoms:

• Avoid lying down or reclining for at least 2-3 hours after meals to prevent acid from flowing back into the oesophagus.

• Elevate the head of the bed to reduce night time reflux symptoms.

• Maintain a healthy weight (excess weight can increase abdominal pressure and worsen reflux).

Instead of relying on long-term PPI use, addressing the root causes of reflux through natural strategies and lifestyle changes can offer a sustainable and natural approach to managing your symptoms - without the adverse health effects!

References
Australian Prescriber, 2023, ‘Top 10 drugs 2022-23’, Australian Prescriber, vol 46, no. 4.

Boyle N, n.d., ‘Your questions answered about PPI treatment for reflux’, RefluxUK, viewed 10 September 2024, link

Lehault WB & Hughes DM, 2017, ‘Review of the long-term effects of proton pump inhibitors’, Federal Practitioner, vol 34, no. 2, 19-23.

LeWine HE, 2024, ‘Are the side effects from PPIs something to worry about, or much ado about nothing?’, Harvard Health Publishing, viewed 10 September 2024, https://www.health.harvard.edu/newsletter_article/proton-pump-inhibitors

Turner JP et al, 2022, ‘Deprescribing proton pump inhibitors’, Australian Journal of General Practice, vol 51, no. 11.

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