Welcome to episode 63 of the Inside Knowledge, I’m Anna Mapson.
Last week I talked quite a bit about what you can do for acid reflux that doesn’t involve medication. Things around changing your eating patterns. Some specific foods that may affect acid production. And the way that your lower oesophageal sphincter can open to let the acid out.
Introduction to Proton Pump Inhibitors
So take a look at those if you haven’t already, because that is the first place to start. But this week I’m going to be talking about the things that we can take from the doctor if you have high levels of stomach acid, reflux, and ongoing heartburn that is not resolved by those kind of lifestyle changes.
The most common medication that you may be prescribed is called a proton pump inhibitor. These are brand names like Omeprazole, Esomeprazole, or Pantoprazole, or Lantoprazole. They all end in -azole, basically.
H2 blockers
But there are other types of medication as well that work in a slightly different way histamine blockers. These are sometimes called ranitidine or famotidine.
These are working in a slightly different way. I’m going to get into the mechanisms of those in a minute. I’m also going to talk about the implications of taking these medications. So what happens when we stop our stomach acid because we do need it.
How is stomach acid produced?
In order to explain how the medications work and the implications of using them longer term, you might need to understand a little bit more about how acid in our stomach is actually triggered. So, sometimes it’s a conditioned reflex that we will anticipate food. You know that you can get that sort of Pavlovian response to a delicious smell.
Maybe your saliva starts going, you start anticipating the food. Maybe your stomach starts rumbling when you’re a bit hungry.
The first stage of digestion starts in the brain
That cephalic response, that’s like our ‘brain stage of digestion’. That can also trigger acid production in the stomach. But we also get an increase in stomach acid when we actually start to eat. Food comes into and stimulates the stomach to release acid.
What is the proton pump?
There are cells lining your stomach called the parietal cells and these have the thing in them that’s called the proton pump. It’s exchanging potassium ions, then we’re getting down to like really chemical structures of your food and your biology. The potassium is being exchanged for hydrogen, so it’s pumping in potassium and pumping out hydrogen.
When hydrogen is reaching other cells, then acid is produced by those. This is why the proton pump inhibitor, which is stopping this proton pump from doing its work, is going to stop the acid production because it stops hydrogen production.
Histamine also triggers stomach acid
Now, part of this as well, at the same time, your vagus nerve, which can be stimulated by your brain and your thoughts, but also by food, starting the mechanical process of digestion. Histamine is also secreted from other cells within the lining of your stomach, which also stimulate the parietal cells to release hydrogen.
And in that way, we’ve got these two methods for creating hydrogen, which then triggers the production of acid.
We can either block the histamine production, or we can block the proton pumps from doing their work, and that will stop acid being produced in your stomach.
How effective is a PPI?
Because the lining of your stomach is being renewed every three days. So there’s constant turnover. Some of the cells are being renewed every second of the day and every second of the night. Over the course of three days, the entire lining of your digestive tract will have renewed itself.
When we take a proton pump inhibitor, it is extremely effective. It can stop the acid production by somewhere like 75 -90 percent. It completely blocks the production of that cell. But, because we’ve got this constant turnover, there will always be new cells that are starting to grow and starting to produce acid. Which is why you need to take a proton pump inhibitor every day.
Taking a PPI every day
Some people who find they take it and are still getting symptoms will find that splitting their dose and taking some in the morning and some in the evening is actually more effective. Because you might have a very fast turnover of cells and you may find that a single dose doesn’t last enough. It’s best to take your proton pump inhibitor in the morning rather than taking it at night before bed because you’ve got the most action during the daytime when you’re actually going to be eating.
When you stop taking a PPI
During that kind of renewal process, every 24 hours, 20 percent of the pumps will be renewed. Within stopping taking your proton pump inhibitor, you’ll be fully back to all the acid production within two to three days. The cells will start to do their work again and you will start to get acid production pretty quickly.
Acid rebound on stopping a PPI
Something that is really common when people stop taking their PPI, they can experience something called acid rebound. You can think about it like your body is still sending the messages to these parietal cells in the lining of your stomach to produce acid.
Imagine like a water dam that is pushing back the water and holding it back so that no water can flow down the river. If you suddenly take that dam away, and you take the brakes away, then you can get a flood of water coming through. And that is the same kind of thing with your acid. Your body does not understand why no acid is being produced. So it sends more and more messages to the cells saying, make acid. Make more acid.
And then, if we take off the brakes, we suddenly release this dam and they’re going crazy creating a lot of acid. Which can then lead to much worse symptoms than maybe you had in the first place. You might stop taking the proton pump inhibitor and actually think ‘I definitely need it there is no way I can stop because it’s so much worse’ and this is down to the rebound effect.
Who needs to be taking a PPI?
Some people who are taking a PPI will just need to be on them for the rest of their lives. Or for as long as they have another condition going on. Some examples of this is people who’ve got Barrett’s oesophagus.
Barratts oesophagus
This is where the oesophageal lining is damaged due to acid burning it. If it continues to be burnt, may lead to cancerous changes in the cells. So if you’ve got Barrett’s oesophagus, unfortunately you need to stay on a PPI for the rest of your life.
Long term NSAIDs usage
Other people who may need to take a PPI longer term are people who rely on pain medication such as ibuprofen. These non steroidal anti inflammatory drugs, will also cause damage to the lining of your stomach. And so we need to protect it by stopping the acid production. If you’re someone who is going to be constantly in need of pain relief, we need to protect your stomach and stop the acid production.
Stomach ulcers
If you’ve got an ulcer inside your stomach, then you also need to stop the acid production for a short time until your stomach lining can heal. If you’ve got oesophagitis. That would be a condition you need to speak to your doctor about, but normally people stay on a PPI because of that.
There are other instances.
Ask your doctor about your PPI use
Do not stop your PPI unless you’ve had a conversation with your doctor. Or unless you understand why you’re taking it.
There are so many people taking a proton pump inhibitor that are taking it for either the wrong reasons or for reasons that they don’t understand. So maybe your doctor put you on it years ago and has never reviewed it and never checked it with you.
Do you actually need to be taking a PPI?
Some research, which was from about 20 years ago in the UK, so I don’t actually know if these numbers have gone up or down to be fair, but about 25 to 75 percent of people were taking PPI’s inappropriately. Which could be a huge drain on the NHS, but also on your health. It’s not without consequence to take something which suppresses your acid in your stomach because we actually need it for our digestion.
Whilst there are those cases of people who must carry on taking it, there are a lot of people taking it who don’t need to be taking it. If you are not sure whether you should be taking a PPI or not. I definitely think it’s worth reviewing it with your doctor.
Do you know why you need a PPI?
For most cases of reflux or esophagitis, proton pump inhibitors should be taken for around 4 weeks or 6 weeks. And yet, a lot of people I work with have been taking them for years. And don’t actually really know why they’re taking them or why they’re taking them. What would happen if they stop? So whilst I definitely don’t recommend stopping without doing some of the things I’m going to come on to now, it’s also really important to just double check whether you should be on it in the first place.
Risks of taking a PPI long term
Some of the risks of taking a proton pump inhibitor for a long time is that we rely on stomach acid to help us absorb key nutrients.
Reduced magnesium absorption
Some of the things you can be really low in include magnesium. Because we need stomach acid to help us with magnesium absorption. And when we’re taking it longer term, it’s easy to become low in magnesium.
Magnesium is also often low when people are stressed, which is one of the reasons why we get stomach ulcers in the first place. Through high levels of stress and not engaging the brain and not engaging your normal physiology in eating.
Magnesium is low when we’re stressed
Remember last week I was talking about the vagus nerve and how you actually need to do that mindful eating, the chewing.
These kind of things are really helpful, but when you’re stressed and you’re chronically anxious, you don’t engage in those behaviors, which can then lead to you being prescribed a PPI, which blocks the stomach acid production.
You might find you are lower in magnesium. Which is actually really important for managing anxiety.
When we’re very stressed, we tend to clench our muscles and feel quite tense, and that uses up more magnesium. So then again, you need more of it and you’re absorbing less.
Vitamin B12 needs stomach acid for absorption
Another thing you can be low in due to blocking stomach acid production is vitamin b12. When stomach acid is lower it is harder to extract b12 from foods which are mostly animal products like meat, fish, eggs, etc.
And without the stomach acid it is harder to extract this vitamin from the things that you eat. This is quite mixed in the research, I would say, but generally, the trend seems to show that people who take PPIs over the long term may be lower in vitamin B12.
Signs of low B12
The signs of low vitamin B12 are often neurological, so things like tingling, numbness in your fingers and legs, sometimes problems with cognition and memory. A whole range of other things including fatigue and brain fog are also really important symptoms.
Can PPIs affect gut health
Another reason that taking PPIs is not great for us longer term is that it can affect your gut microbes in your large intestine. It can reduce gut diversity in the short term and it may also change over the long term.
We know that there are links to increased risk of Clostridium difficile infection, but also just generally reducing the diversity. So when you have less types of bacterial species in your large intestine, there’s more chance for those kind of infectious pathogens to get in, make your gut their home, and make themselves at home basically in your body.
PPIs may lead to SIBO
Then we also know that taking a PPI may affect your chances of getting SIBO. So as I mentioned in the introduction, small intestine bacterial overgrowth may be more of a risk when you have removed one of the first lines of defense. Which is your stomach acid. And that is one of the ways we block pathogens from getting into the gut.
The stomach acid normally kills them off. But if your stomach acid is reduced in order to protect the mucous lining of your gut and your stomach and to reduce burning in your esophagus, then you might be increasing the amount of bacteria getting into the small intestine.
So it’s not without consequence to stop that production of acid. This doesn’t happen in everyone.
Can PPIs even cause SIBO?
Actually there was a study out earlier this year, so quite recently, that was shown people who took Pantoprazole 40 milligrams, once a day, it was quite a small study, only 38 people, and they were healthy.
On over 7 days, they gave them this medication that blocked their stomach acid production, and 7. 8 of these people developed symptoms like bloating and gas and an increase in bacteria in their small intestine. Which they measured with a breath test. When I say it was 7.8% is actually two people out of 38, which also means 92 percent didn’t get SIBO.
Okay, so I don’t want people to take all these, research studies out of context. The way the information is presented can be very leading and guide you to certain conclusions. So the researchers obviously here are trying to suggest that people shouldn’t take PPIs because it’s a risk of SIBO.
Reading the research correctly
Whilst that is true, that yes, two people out of 38 did end up with increased bloating and increased gas and on a breath test had higher levels of hydrogen. However, most of them didn’t. And when we look at it like that, it also needs to be put into context. So there’s a potential risk, but it is very small.
And I think there’s quite a lot of fear mongering around taking PPIs, that it is definitely going to give you SIBO, that you are going to make SIBO worse if you start taking a PPI. Which is not necessarily the case. If we look at actual evidence and what the case reports and research studies are showing us.
Iron absorption
The other thing that might be affected by taking a PPI is your iron absorption, because again, it normally relies on a certain pH level to best absorb iron. When your proton pump inhibitor is blocking acid production, you may absorb less iron. Now iron can also, transport oxygen around the body.
Blood tests to check nutrients are important
Think about those ferritin stores that are so important. So, making sure if you are taking a PPI, then you should be getting regular checks to make sure that your levels of magnesium, iron, B12. Just generally the rest of your, metabolic signs are all healthy because there is a consequence of having less intake of those nutrients.
I just want to make sure that you are aware of what it can do. And then you can take some steps to get around it. Maybe the steps are you need to take an iron supplement?
But don’t take an iron supplement unless you know you actually need to same with magnesium. Maybe your levels are low of magnesium. And so taking a supplement regularly would actually help you.
Risk of bone fractures
Linked to all of these nutrient deficiencies, there is a potential increased risk of bone fractures as well on long term acid reduction medication and that is due to decreased calcium absorption.
So there is a potential risk for lower bone density over time. Particularly in postmenopausal women or people who are elderly or who have other factors for osteoporosis. So we want to make sure that those things have been thought about and are regularly being monitored by a doctor.
Do you need a PPI if you have a hiatus hernia?
Sometimes people will be prescribed a PPI because they’ve got a hiatus hernia. This is where a small bit of your stomach goes up through the diaphragm, which is a wall of muscle that goes across your torso. And your stomach is not supposed to go above this, but sometimes it can pop up. That can also give you the symptoms of heartburn and that irritation.
Not everybody who has a hernia definitely needs to take a PPI longer term. Sometimes people will be put on a PPI and then never reviewed. If this is the reason you’re taking a PPI, it might be worth thinking about whether you actually need it or not.
I kind of wanted to end this episode on a story of caution about listening to people online.
Talk to your doctor
So if you’ve been prescribed a PPI by your doctor and they’re suggesting that you need to reduce your stomach acid, it is for a reason.
Often it is to protect the lining of the stomach or to get symptoms under control to avoid a stomach ulcer. Whatever it is, there are valid reasons for needing to suppress acid. It’s not going to necessarily cure your reason for having that ulcer in the first place, but it might give you the breathing space to enable you to work on your digestion, sort out your stress, whatever it is.
Proton Pump Inhibitors can give you a break
The PPI is more like a sticking plaster, and plasters are helpful in some cases. They give us a break. Medication is there to help us and allow us to do the other work that is important around regulating your bowel movements. Making sure your diet is good and healthy.
Sometimes people need to take an antidepressant to get them through a really tough time in their lives. It doesn’t mean that you have to take it forever. And it’s not helpful when there are people online in groups creating quite a lot of fear around certain medication. I think PPIs are one of them.
Finding what works for you
However, as I’ve been through in this episode, there are consequences of taking it that long term if you’re not managing it. If you’re not thinking about it, it could lead to imbalances.
If you’re low in iron and you’re low in B12, you could feel very, very tired with brain fog and fuzzy. You could be finding it hard to get up and get motivated. These kinds of things are. really challenging. You wouldn’t necessarily relate it back to PPI usage unless you knew that it reduces iron and B12, for example.
So I hope this episode has been helpful in just showing you some of the reality about why we need to take these drugs and also what you can do in order to monitor them.
What about H2 blockers?
Now I I have talked a little bit about the other ones like H2 blockers. They basically do very similar jobs. They’re both suppressing acid production.
People say H2 blockers are better, but they’re both doing the same thing by stopping your acid production. So you’re going to get the same consequences in terms of nutritional deficiencies, potential increase in changes in your gut microbes. And that can happen within a couple of weeks, whichever of these type of medications that you’re taking.
The best thing to do is to talk to your doctor and have a good and honest conversation about it. And if you haven’t had that reviewed for a number of years and you’ve just been getting it on repeat prescription, then make an appointment to have a review.
How to stop acid rebound
In order to combat some of that acid rebound that I talked about, that happens when you stop. So if you had a conversation with your doctor, you’re ready to stop.
Preparing to stop taking a PPI
Some of the things that you need to get in place are regular meals. Making sure that your diet is a good balanced diet, that you have got great sources of fibre in there, that you are eating enough protein and balancing out your blood sugars.
These things are really helpful because when you come off the acid blocking medication, there potentially will be changes. Not everybody gets this rebound by the way. But it is helpful to make sure that your body is in a best place it can be before you stop. Some of the things you can do is making sure that you have worked on your stress levels. You are sleeping well. You’re well hydrated because you need to produce acid at the right time.
You want to make sure that that’s all working well.
Nutrients for acid production
You may want to look at things like B6 and Zinc because they are also involved in stomach acid production. So I’m not saying everybody should go and take them, but you might want to think about whether that is going to be a helpful support for you as you start to think about removing the PPIs.
There are a whole load of supplements that also can be taken to start soothing the gut lining to increase the mucus layer. Things like Slippery Elm may be helpful. There are also things that support production of the mucus. Because you want to try and regulate that as well. And then eating patterns. Making sure your mucous lining and gut is well supported. Also that your diet is well balanced.
This can take a little while to get in place, so before you do any of the stopping of PPIs, you need to make sure that you’re eating well and everything else is in as good a place as it can be.
Working with reflux and SIBO
trying to resolve SIBO, for example, I would suggest that you try to resolve symptoms of SIBO before you try and stop. Because that can be one of the triggers for having significant, acid coming up into the oesophagus. Where you’ve got a lot of pressure and a lot of gas in the torso due to SIBO. It’s complicated and that’s why I really suggest working with somebody who knows about acid reflux, PPI’s and, SIBO. IBS, so someone like me.
The 3 month Gut Reset
And I can do that with you. So over three months I work with people in my gut reset, and in that time I work with you over six weeks talking weekly, and in those sessions we talk about how to improve your diet, how to improve your eating pattern to maximise your chances of getting a better digestion.
If you’re interested in that, then please drop me a line and set up a call. where we can chat about what you need help with and also how I work.
Thank you for listening to this episode of the Inside Knowledge for people with IBS. Better digestion for everybody.