Heartburn remedies may harm

Saiesh, our gentle friend, bragged that he could now eat more of the pungent food he liked and yet keep his stomach serene and calm just by taking a tablet of “omeprazole” every day. Vijay, who enjoyed his Scotch on the rocks, boasted that he could gulp an extra peg and yet keep that nagging “heartburn” away by swallowing a tablet of “Lanseprazole” daily.   Both Omeprazole and Lanseprazole belong to the class of drugs called PPIs (proton pump inhibitors):  effective agents for reducing stomach acidity and reflux.  But beware!  A red alert has recently been sounded that PPIs taken over a long period could lead to chronic kidney ailments.

“Heartburn” is a form of indigestion which translates into a burning sensation in the chest, caused by acid regurgitation into the esophagus. The esophagus is a tube that connects the mouth to the stomach; it comprises muscles that work to thrust what we eat toward the stomach. Once in the stomach, food is prevented from refluxing (moving back into the esophagus) by the lower esophageal sphincter (LES). The stomach combines food, acids and enzymes together to begin digestion. There are special protective cells that line the stomach to prevent the acid from causing inflammation. The esophagus does not have this same protection, and if stomach acid and digestive juices reflux back into the esophagus, they can cause “heartburn” subsequent to inflammation and damage to its unprotected lining.

Many common foods that we eat and drink stimulate an increased stomach acid secretion, setting the stage for heartburn. Examples of these irritants include: alcohol, caffeine, aspirin, ibuprofen, carbonated beverages, acidic juices and foods. Smoking and the consumption of high-fat content foods also tend to affect the function of LES by allowing acid to reflux into the esophagus. A “hiatal hernia”, where a portion of the stomach lies within the chest instead of in the abdomen, can affect the way the LES works and is a risk factor for reflux.  Pregnancy and obesity can cause increased pressure within the abdominal cavity as well, affecting LES functioning and predisposing us to reflux and heartburn.

Medicines used to treat “heartburn” include 1) antacids; 2) H2 (histamine) receptor blockers;  3) PPIs (proton pump inhibitors). Antacids are a class of medicines that neutralize acid in the stomach (Gelusil, Diovol). Histamine-2 (H2) Blockers (Zinetac, Ranitin) effectively relieve heartburn and treat reflux, especially if you have never had treatment before.  But it is the PPIs (Omez, Ocid) which block acid production most effectively and for a longer period of time than the H2 blockers.

Ever since PPIs became available, they have been consumed excessively:   many patients either self-medicate or find it a common ingredient in their doctor’s prescription. Unfortunately, studies have revealed that they can lead to long-term kidney damage. Recently published  research in the journal  Kidney International  proves  that abuse of PPIs heralds “a silent disease  because  it erodes kidney function gradually over time," according to Ziyad Al-Aly, the study's senior author and assistant professor of medicine at Washington University's School of Medicine. Al-Aly and his colleagues analysed data from 125,000 US patients using PPIs and found more than half went on to develop chronic kidney damage despite the absence of prior kidney problems. Even a small potential increase in risk can progress into something major, given that the drug is being so commonly prescribed to millions of people over a long period of time.

This is not the first time that PPIs have led to health concerns. Their use has been linked to increased rates of fractures, pneumonia, gut infection and low vitamin B12 and magnesium levels. "These drugs should be used at the lowest possible dosage and for the shortest possible duration, appropriate for the condition being treated," according to recent health warnings. Emily McDonald, an internal medicine specialist at the McGill University Health Centre in Montreal, suggests trying other interventions such as altering one’s diet before resorting to  PPIs — and where they are absolutely necessary, following up regularly to re-evaluate whether a patient needs to continue using them. "We must constantly review how many people are on these medications, and how many are on them unnecessarily. PPIs, given indiscriminately for heartburn, point to over-medication,” she says.

It is true that PPIs are extremely effective for people who need them, especially those with gastrointestinal bleeding or ulcers. But even here it is recommended that doctors de-prescribe those who don't need to be taking them, especially in cases where the possibility of an adverse outcome outweighs any benefit. Instead doctors should suggest simple strategies to prevent heartburn, before drugs are used:  a) Avoiding acidic and spicy foods, b) Decreasing alcohol consumption and stopping smoking. c) Using gentler medications before "pulling out the big guns" of proton pump inhibitors. There is always the urge to provide the quickest panacea to patients, but the fastest method in medicine isn't necessarily the wisest.

As an aside, I am reminded that the word “heartbreak” is similar to “heartburn”.  Given the two alternatives, which one would you opt for?  Heartbreak sucks way more than heartburn ever can.  But heartbreak makes for good poetry and heartburn doesn’t! In the end the choice is yours. The message one should capture here is, “When troubled with heartburn, refrain from over-medication. Try changing your lifestyle instead! ”

(Dr. Francisco Colaço is a seniormost consulting physician, pioneer of Echocardiography in Goa.)