Brooks Cash, MD
Brooks Cash, MD, Chief of the Division of Gastroenterology, Hepatology, and Nutrition at UTHealth Houston and the Dan and Lillie Sterling Professor of Medicine at UTHealth McGovern Medical School.
The first proton pump inhibitor (PPI), omeprazole, was available by prescription in 1993. Since then, PPIs have gone over the counter. You probably know them by their brand names, including Nexium (esomeprazole magnesium), Prilosec (omeprazole), Protonix (pantoprazole), Aciphex (rabeprazole), and Prevacid (lansoprazole). For more than 25 years, they have proven to be a safe and effective treatment for heartburn.
PPIs work by blocking an enzyme in cells of the stomach that release stomach acid. The cells are called parietal cells, and the enzyme is like a tiny acid factory inside the cells. Although PPIs are often called acid blockers, they don’t completely block acid secretion; they just reduce it.
PPIs are popular because they work well, but there’s a concern that they are being overused.
Over the counter PPI labels say they should be used for only two weeks, but many people stay on them for years because their heartburn comes back as soon as they stop.
Because PPI use is so common, a study published the journal Neurology in the summer of 2023 got some attention in the media. It followed 6,000 older adults for five to six years and reported that PPIs used for more than four years in people over age 45 were associated with an increased risk of dementia.
Although the authors qualified their findings as class III (not as strong as top-notch studies), the media jumped on the story. However, when the results were interpreted with a statistical method to minimize the effects of confounding risk factors called logistic regression analysis, the increased risk dropped away completely, but this aspect of the analysis was omitted by many media outlets in their coverage of the study results. Importantly, a larger and more rigorous, but less well reported, study was published in the journal Gastroenterology in June of 2023. Researchers from Massachusetts General Hospital and Harvard University followed nearly 19,000 older adults for up to seven years and found no association between PPI use and dementia.
Over the years, various observational studies have suggested that PPI use can increase the risk of heart attack, stroke, osteoporosis, and, most recently, dementia, but none of these studies have been conclusive and more recent, methodologically robust, prospective clinical trials evaluating the safety and possible associations with PPIs and other chronic medical problems have found that PPIs are not associated with the development of these chronic medical conditions.
Doctors usually prescribe a PPI to treat long-term symptoms or diseases caused by abnormal gastric acid exposure to parts of the upper GI tract. This includes conditions like gastroesophageal reflux disease (GERD) or erosive esophagitis. PPIs are also used to treat peptic ulcers in the stomach and/or small intestine as well as infection of the stomach with a bacteria called H. pylori that can cause ulcers and is a risk factor for gastric cancer. Over-the-counter PPIs are the same drugs as doctors prescribe, but may be a lower dose than what a doctor may prescribe. For some patients, a PPI may be needed indefinitely, and this is called chronic, or maintenance, therapy.
If you decide to try a PPI for heartburn on your own and it improves your symptoms, you should try to stop after two weeks. If the over-the-counter PPIs do not help your symptoms or if your heartburn returns after discontinuation of the PPI, you should talk to your health-care provider about your symptoms. The cause might be GERD (the most common cause of chronic heartburn), but there could also be something more serious that is causing the symptoms.
It is important for your healthcare provider to be aware of these symptoms because long-term heartburn is associated with a condition called Barrett’s esophagus, which is a change in the tissue lining of the esophagus that can lead to esophageal cancer in some patients.
You should also know that suddenly stopping PPIs you have been using regularly can result in too much acid production and worsening symptoms, so it is advised that you taper off these medications when stopping them if you have been taking them regularly for more than a couple of weeks. Try dropping down to every other day and then gradually stopping over several days. If you experience recurrent heartburn, see your doctor. If your heartburn or upper abdominal pain is due to a condition like GERD or an ulcer, it will often recur after stopping PPIs.
Any OTC drug has some potential for overuse, and there are a multitude of conditions for which PPIs are commonly used that could be resolved with other medications. For only occasional heartburn symptoms, you might be able to get relief from a simple antacid tablet, like Tums or Rolaids.
You can also try an H2 receptor blocker. These acid blockers are not as effective as PPIs for chronic or frequent heartburn, but they help occasional heartburn. H2 blockers include over-the-counter drugs like famotidine (Pepcid), Tagamet (Cimetidine), and nizatidine (Axid). It is generally recommended that if you are having bothersome heartburn or regurgitation symptoms more than two to three times per week, you should discuss these symptoms with your health-care provider.
PPIs are great medications for people who have chronic heartburn or other peptic acid-related conditions. The most common of these is GERD, but there are other, more serious causes of these symptoms that may be present. The best way to treat chronic heartburn is to work with your health-care provider to identify the cause as well as the best treatment.
PPIs are safe as well as effective, and for some people they may be needed indefinitely, but should not be used over the counter for long periods without a diagnosis.
Several lifestyle changes can help reduce heartburn:
Always let your doctor know if:
