Is it safe to take PPI medications?

Proton pump inhibitor medications (also known as PPIs), such as omeprazole, lansoprazole, and esomeprazole, are some of the most widely prescribed medications in the UK and the world, with over 1.5 million prescriptions issued in the UK alone. Once only available on prescription, you can now buy Nexium (esomeprazole) over the counter in pharmacies. These medications have been a game-changer for the treatment of several gastrointestinal conditions since their release in the late 1980s, and remain a key part of our tool kit in gastroenterology practice.

What are PPIs, and what are they used for?

PPIs block a cellular pump in certain stomach cells, reducing the acidic secretions into the stomach. They are very effective at this, dramatically lowering the acidity in the stomach and the volume of secretions. This can be hugely helpful in a number of conditions where stomach acid is worsening symptoms.

PPIs are commonly used for:

• Treatment of peptic ulcer disease, like stomach and duodenal ulcers

• Part of the eradication treatment for H. pylori infection

• Reducing stomach inflammation (gastritis)

• Healing inflammation of the oesophagus caused by reflux (oesophagitis)

• Improving symptoms of heartburn and reflux

• Improving abdominal discomfort called dyspepsia

PPIs have become so widely prescribed because they are very effective. They are often used for symptoms like reflux, heartburn, and abdominal discomfort, and many patients respond very well to treatment. It is important to take the medication correctly - it is most effective taken 30-60 minutes before breakfast if taken once a day.

Are PPIs safe? What are the risks of long-term PPI use?

But are PPIs safe? We now have a great deal of safety data about these medications from nearly 40 years of use in tens of millions of people, and yes, PPIs are overall very safe for short term use, and when prescribed appropriately in the short term the benefits will outweigh the risks.

However, all medications do have some risks, and PPIs are no different. This is most important with long-term use (over 3-6 months or so), when a more careful discussion of the risks and benefits is needed.

The known risks of PPIs include:

• An increased risk of infection with the bacteria C. difficile

• Problems with the absorption of some nutrients (calcium, iron, vitamin B12)

• A slightly increased risk of bone thinning (called osteoporosis)

• Low levels of magnesium in the blood

• A slightly higher risk of chest infections (mainly in older patients in hospital)

• Small risks of a kidney condition called interstitial nephritis

There have been more recent concerns about a possible small increased risk of dementia in long-term PPI use. The studies about this don’t all agree, and it is unclear how PPIs would cause dementia, so it remains unclear if this is a true risk of the medication, or just an association in some studies.

What do we do for people who need PPIs long-term?

So what should we do for people who are requiring PPI medications for longer periods? My approach is to carefully look for the cause of symptoms and investigate as appropriate. We can then use all the tools at our disposal, including diet, lifestyle changes, medications, and sometimes surgery, to treat the underlying cause of problems, and I often work with patients with the aim of reducing or stopping PPI medications. Often symptoms can be radically improved with non-medication approaches.

I then discuss how to reduce and stop PPI medications. This can be tricky, as often the stomach will make excess acid when PPIs are stopped, leading to severe ‘rebound’ symptoms when the medications are stopped. These can last for a couple of weeks, and are frequently the reason people restart PPIs, and think they cannot come off them. With the right support many patients can reduce and stop these drugs. I also discuss medication alternatives, including other medications that lower stomach acid less dramatically, over the counter antiacids, and natural remedies which can be helpful.

However, there are lots of people who do require these medications in the long term, either because of underlying medical issues requiring acid suppression (like Barrett’s oesophagus) or where the medications really help their symptoms. In this case, the key is to ensure patients are on the lowest effective dose of PPI to control their symptoms or condition, and that they are appropriately informed about the risks and benefits of long-term use.

If you have persistent symptoms that you take PPIs regularly for, and want to get to the root of your symptoms or reduce your requirement for these drugs, do get in touch with my team who can arrange a consultation.