Do not make any changes in PPI use without consulting a physician first! Make sure that you are closely monitored during the process of lowering your dosage of PPIs. It is also important to have doctors watch other medications you may take. The return of normal acid levels in the stomach can change the absorption level of many medications.
According to the American Gastroenterological Association more than 60 million Americans experience acid reflux monthly, and up to 20% of those suffer from gastroesophageal reflux disease (GERD), a condition of chronic acid reflux. Heartburn is the pain caused by refluxed stomach acid irritating the esophageal lining. Antacids are usually sufficient in treating the majority of heartburn sufferers, but those with GERD are frequently prescribed a Proton Pump Inhibitor (PPI) by their primary care physician or gastroenterologist.
PPIs reduce or eliminate the pain associated with GERD by blocking the stomach’s production of acid, thus lowering the acid level in the stomach that might reflux into the esophagus and irritate the lining. There is no question about it. PPIs can be used effectively to help in the healing of ulcers, acid damage, and with antibiotics from Helicobacter pylori,1 but is it the right choice for the treatment of your condition?
Misuse of PPIs
While PPIs provide relief, they do not cure GERD. They only mask the problem by removing the pain associated with heartburn. If the medication is removed, the symptoms are likely to recur, thus proving this to be an ineffective treatment for GERD. The only way to cure GERD is for the sufferer to take an active role in managing the disease through a lifestyle change. Too many of us take the easy way out and do not take care of ourselves like we should. Eating healthy foods in proper proportions, limiting alcohol, and being physically active are some of the basics in lifestyle change that will eliminate GERD for most people.
Many suffering from heartburn take PPIs without fully understanding how they are to be used. This is partly due to the lack of self-education on the part of the patient and a failure on the part of many caregivers to provide patients with proper instructions on how to take the drug. This lack of knowledge and fact that many PPIs are available as over-the-counter (OTC) medications lures patients into a false sense of security in the drug’s safety. Too many patients continue taking PPIs for months or years because they do not understand the risks. In the United States, the packaging on OTC PPIs clearly directs taking it for no longer than 14 days or more often than every 4 months unless directed by a doctor. This is to prevent negative side effects that can occur when using the medication long term. Though your doctor may prescribe you a PPI for a different time interval depending on your health issue, they are to be taken short term and in the lowest dosage and interval possible to achieve the desired effect while healing from acid irritation takes place.
Long term or large dosage use for GERD, acid reflux, or heartburn is a poor choice for those without severe symptoms. PPIs are valuable in the short term treatment of GERD, but long term use may lead to the following health issues:
- Increased risk of heart attack. 2
- Increased risk of pneumonia.
- Bacterial infections introduced through foods.
- There is increased risk of having an Clostridium difficile infection. 3
- Decreased absorption of vitamin B12, calcium, magnesium, iron and other nutrients leading to bone fractures, hypomagnesaemia and cardiac arrhythmias. 4,5
- Reduced ability of the lower esophageal sphincter (LES) to close due to low stomach acid levels. Higher acid levels are needed to induce the proper closure of the LES.
- Increased risk of Barrett’s esophagus which can lead to cancer. 6
[For greater details of long term use, side effects, and an understanding of the use of PPIs in treatment, please see the article “PPI – Proton Pump Inhibitor“.]
4 Reasons for weaning off PPIs
- If you are exceeding the recommended dosage, you are outside the FDA’s guideline for use of the drug and are at risk of great health problems.
- If you initiated taking PPIs without a doctor’s approval and guidance. Though available in OTC form, PPIs should not be taken without direction from your doctor.
- If you are taking them for regulating heartburn and not for relief from heartburn while healing from damage caused by acid erosion.
- If you are breastfeeding, pregnant, or may become pregnant. They can expose the baby to risk. 7
What are the side effects of weaning off PPIs?
Steps for Weaning off PPIs
- You should consult with a physician before making any change in PPIs and implementing the 5R Program for Lifestyle Modification listed below. Your doctor can determine this and if the 5R Program is set up right for you. We are all different and modifications might be needed to accommodate your health conditions and any medications you may take.
- Do not attempt to wean off your PPI if you are being treated for ulcers, acid damage, Helicobacter pylori, or other condition where PPIs are needed for treatment. Your doctor can help you make this determination.
- The return of normal acid levels in the stomach can change the absorption level of other medications you take.
- If medications are controlling your symptoms you may be able to reduce the dose of PPIs you are on or wean off them altogether. GERD patients are often prescribed PPIs in dosage and frequency higher than needed. We are all different and the doctor is only making an estimate of what amount you might need to control your symptoms. If you happen to be one of the many who are overprescribed PPIs, symptom control may be achieved at a lower dosage, frequency, or even with a less potent form heartburn medication like a H2 blocker.
- There are 3 levels of heartburn medications. They control the symptoms of heartburn but do not cure the underline cause of heartburn. If a lower dosage of PPIs or a lower level heartburn medication can treat your symptoms, it is important for your health to find the minimum level of treatment while still controlling heartburn.
- Level 1: Antacids help neutralize stomach acid. They act quickly but are short-lived, usually less than 2 hours. They are great for combatting the occasional heartburn brought on by ingesting heartburn trigger foods or drink.
- Level2: Histamine receptor blockers (H2 blockers) decrease stomach acid production, thus decreasing heartburn due to acid reflux. H2 blockers can provide up to 12 hours of relief.
- Level 3: PPIs are used when antacids and H2 blockers aren’t providing relief. It may take days before they start providing relief, usually 48-72 hours.
- We must understand that GERD is not caused by too much acid, but by acid being refluxed into the esophagus where it does not belong. Stomach acid can reflux when the LES doesn’t close properly. Acid is actually needed. It just needs to be in the stomach where it belongs. Acid triggers the LES to close keeping the acid out of the esophagus. Certain foods, over eating, abdominal pressure, medications, alcohol and nicotine are the main offenders that can effect an otherwise properly functioning LES. These offenders can relax the LES or impede it’s closure allowing acid to reflux into the esophagus.
- Lifestyle choices are tied to GERD in most cases. A positive change in diet, exercise, and stress levels will be required to wean off PPIs. This also includes a reduction in weight for many which will likely occur when the change in diet, exercise, and stress management are implemented.
- It is important to make small gradual reductions when you wean down your intake of PPIs.
- Many are fortunate and can easily lower PPI dosages. Some, however, cannot wean off PPIs because their disease has progressed too far and will have to stay on PPIs. Remember PPIs do not cure GERD. They only mask the pain. The disease can still progress while taking PPIs. The goal when unable to stop taking PPIs is to find the right level of medication for your health and wellbeing and no more.
- We are all different. What works for one may not work for another. It is important to take it slow and step back if your symptoms substantially increase.
- It will be easier for people with less severe GERD issues to wean off PPIs and also easier for those who have taken the drug for a shorter time period and at a lower dosage than those with more severe issues who have taken high dosages for many years. There are even a significant number of long term users taking PPIs for GERD who were misdiagnosed and don’t even need to be on the drug. This is primarily seen in those who did not have a endoscopy performed proving erosive esophagitis or a positive pH test. Weaning off PPIs will be easiest for these who were misdiagnosed.
- Keeping a heartburn journal during this time will help you understand your triggers and any setbacks you have while you wean of PPIs.
- The ultimate goal of this program is to wean off PPIs and return the stomach to proper function.
B. The 5R Program for Lifestyle Modification
If you have a proven diagnosis of GERD, and have not changed your lifestyle, you will still have GERD when you wean off your PPI. This is because PPIs do not cure GERD. They control the pain of heartburn by reducing acid irritation. Heartburn will return if lifestyle changes aren’t implemented. GERD can only be corrected through diet, exercise, and stress management.
We can address the treatment of GERD by addressing the 5Rs of functional medicine: remove, replace, repopulate, repair and rebalance. Depending on your overall physical condition, the 5R Program should be in place one week to a month before you begin to wean off your PPI. Stomach acid is needed to properly break down food for absorption, so the dietary changes will become additionally effective when the stomach is back to producing acid at its optimal level.
- Remove. Remove the heartburn triggers.
- Heartburn trigger foods: Processed food, fried food, fatty meats, dairy products, spicy food, the allium family (garlic, onions, shallots, leeks, and chives), tomatoes, acidic fruits, alcohol, coffee, caffeine, carbonated beverages, mint, chocolate, and candy containing acid in any form. Foods you are allergic to may also cause you heartburn and should be avoided. It would be good to keep a heartburn journal to log any other foods that might trigger your heartburn. We are all different and some food might cause you problems where they wouldn’t someone else. Trigger foods should be avoided because they can cause increased acid, irritation, and weaken the closure of the LES.
- Excess weight: Most of us could stand to lose a little wight around the middle. Extra weight causes pressure on the LES.
- Tight Clothes: Avoid tight fitting clothes around your waist and stomach to prevent added pressure on the LES.
- Poor eating styles: Do not over eat and smaller meals are best. Consider 4-5 small meals spaced throughout the day instead of the typical three. Eat slowly and chew properly. Putting the utensils down after each bite helps slow down eating. Following these eating guidelines will help aid the digestion process, let us know when we are full, and help us relax.
- Poor positions: Remain upright during the day. Reclined and slouched positions cause stomach contents to press on the LES.
- Nighttime heartburn triggers: Fast 2 or more hours before bed. Sleeping with your torso elevated by placing six inch blocks under head of bed or using a wedge pillow will help stomach acids from refluxing. And lying on your left side allows the stomach to hang lower preventing its contents from placing as much pressure on the LES.
- Tobacco/nicotine: This includes smoking tobacco, chewing tobacco, nicotine patches and nicotine gum. These products cause irritation and relaxation of the LES along with other heartburn producing side effects.
- Medications: OTC and prescription medications along with supplements may cause heartburn. It’s best to consult your doctor to see if some heartburn producing medications can be taken in the morning or hours before bedtime to reduce the chances of nighttime heartburn.
- Stress: Learn how to de-stress.
- Nutrition: When the heartburn trigger foods are removed, we are left to eat more nutritious foods which will boost our overall health and help us maintain a healthy weight.
- Vitamins and minerals: PPIs cause deficiencies in vitamin B12, calcium, magnesium and iron. Supplements may be needed to raise your levels of these.
- Acid: Consider taking a betaine hydrochloride supplement. Some people benefit from adding acid. Acid aids in proper function of the LES, breaks down food and stimulates digestion. Avoid any betaine hydrochloride supplement containing NSAIDs or steroids.
- Probiotics: Low stomach acid levels can allow unhealthy bacteria to flourish in your gastrointestinal tract. Consider taking probiotic supplements and ingesting fermented food or drink containing probiotics to reintroduce them into your system.
- Prebiotics: Prebiotics are non-digestible carbohydrates that that serve as a food source for probiotics. Prebiotics are available in supplement form and many foods such as artichokes, asparagus, bananas, barley, beets, carrots, flax, garlic, leeks, legumes, oatmeal, onion, radishes, wheat and more.
- Repair. Mucilage is a thick, gluey substance found in plants that helps coat and build up the mucous membrane of your gastrointestinal tract to protect against acid and promote healing. Take one or more of the following forms of mucilage. If you are experiencing esophageal irritation, make sure to take a form that coats the esophagus and not take the capsule or tablet form.
- Licorice in deglycyrrhizinated form, DGL
- Aloe vera juice reduces inflammation and irritation. It also promotes healing, though it can serve as a laxative as well, so watch how much you take. You might look for some with the laxative component removed. Only use forms of aloe that are prepared for internal use.
- Slippery elm
- Marshmallow root
- Throat Coat Tea (Traditional Medicinals) contains licorice root, slippery elm, and marshmallow root.
- Decrease stress: Stress can increase sensitivity to acid and should be managed through exercise, enjoyable activities, soothing music, aromatherapy, meditation, prayer, massage, pets, friends, sex with a partner, laughter, sleep, etc.
- Exercise: Wait two or more hours after eating to avoid added pressure on the LES.
C. Weaning Process
There is no infallible way to know if you will be able to decrease or wean off PPIs without trying. We are all different and have to be treated as such when making medical choices. This is the main reasons why it is important to have your doctor approve and monitor your progress when you wean off PPIs. That said, weaning off PPIs has been successful in the majority of patients. 10 If you have a rebound of heartburn during the following steps, back up in the process and take it slower. Also, consult your physician.
The basic steps to wean off PPIs:
- Gradually reduce the dosage by 25%-50% each week until you are at 25%-50% of your current intake. If you go at 50%, this will take one week. If you go by 25%, this will take 3 weeks. The slower the weaning process the less likelihood of acid rebound hyper-secretion.
- Once at a low daily dose, reduce the frequency in which you take the drug until you are off the PPI. If you are taking the drug twice a day, step down taking it once a day for a week. When down to once a day, step down to taking it every other day for a week. If heartburn becomes severe, in either or both of these steps try substituting a H2 blocker where you once took the PPI.
- Step down to the use of a H2 blocker and/or antacid once the above two steps have been completed. Though H2 blockers don’t have the severe side effects PPIs have over the long term, it is healthy to keep weaning down from H2 blocker to antacid use alone. Taper off the H2 blocker over the next 2-4 weeks using similar steps to those above.
- At this point you should be able to treat the occasional heartburn on demand with antacids or with antacids and H2 blockers when necessary.
- Once you have weaned off the H2 blocker you may find you have no need for the mucilage. You can stop taking it or go through a weaning off of it as well.
Remove and Rebalance, the first and fifth Rs of the 5R Program for Lifestyle Modification will have to be adhered to throughout your life to prevent GERD from recurring. The other three Rs need to be revisited where necessary. If you are adhering to the steps of Remove and Rebalance and heartburn becomes more frequent, revisit the other three.
In the Maintenance phase after weaning off the PPI, you should be able to take antacids or antacids and H2 blockers when necessary. You may also find natural heartburn remedies helpful. Don’t be discouraged if the occasional round of PPIs are also be needed in your future. When taking future dosages of PPIs, adhere to the acceptable amount recommended by the FDA taking it for no longer than 14 days or more often than every 4 months. Remember to always take the lowest level of medication you can while keeping your symptoms within your level of satisfaction.
Don’t rush the process when you wean of your PPI. Remember, the longer your have taken them the longer you will want to take when weaning off to prevent an overproduction in acid. We are all different so consult your doctor before you wean off your PPI. Some people need to take them for longer periods of time than others.
- US National Library of Medicine National Institutes of Health “Pharmacology of Proton Pump Inhibitors”.
- PLOS|ONE “Proton Pump Inhibitor Usage and the Risk of Myocardial Infarction in the General Population”
- U.S. Food and Drug Administration “FDA Drug Safety Communication: Clostridium difficile-associated diarrhea can be associated with stomach acid drugs known as proton pump inhibitors (PPIs)
- U.S. Food and Drug Administration “FDA Drug Safety Communication: Possible increased risk of fractures of the hip, wrist, and spine with the use of proton pump inhibitors”
- U.S. Food and Drug Administration “FDA Drug Safety Communication: Low magnesium levels can be associated with long-term use of Proton Pump Inhibitor drugs (PPIs)”
- US National Library of Medicine National Institutes of Health “Proton Pump Inhibitors: The Culprit for Barrett’s Esophagus?”
- US National Library of Medicine National Institutes of Health “Are proton pump inhibitors safe during pregnancy and lactation? Evidence to date.”
- Gastroenterology “Proton-Pump Inhibitor Therapy Induces Acid-Related Symptoms in Healthy Volunteers After Withdrawal of Therapy”
- The American Journal of Gastroenterology “Dyspeptic Symptom Development After Discontinuation of a Proton Pump Inhibitor: A Double-Blind Placebo-Controlled Trial”
- Gastroenterology “Step-down Management of Gastroesophageal Reflux Disease”