Balancing risks and benefits of using heartburn and peptic ulcer disease pills in seniors.

Esophagitis and peptic ulcer disease. (Dr. Noorali Bharwani)
Esophagitis and peptic ulcer disease. (Dr. Noorali Bharwani)

About 25 per cent of Canadian seniors suffer from three or more chronic illnesses and are on six or more medications per day.

One of the medications is Pantoloc. Pantoloc (pantoprazole) belongs to the family of medications called proton pump inhibitors (PPIs).

First introduced in 1989, PPIs are among the most widely utilized medications worldwide, both in the ambulatory and inpatient clinical settings. These medications are central in the management of reflux disease and are unchallenged with regards to their efficacy.

Pantoloc is the fifth most commonly prescribed drug. It is used for patients who have heartburn (GERD or gastro oesophageal reflux disease) or inflamed oesophagus (esophagitis). It is also used for peptic ulcer disease (duodenal or gastric ulcers).

The prevalence of heartburn and reflux disease increases with age and elderly are more likely to develop severe disease.

Treating inflamed oesophagus (esophagitis) due to reflux:

PPIs are indicated for short-term treatment of mild esophagitis. Treatment is usually for four to eight weeks duration. But if you have moderate esophagitis with endoscopic evidence of Barrett’s oesophagus (a premalignant inflammation of the oesophagus) and severe esophagitis grade C or D, then you need long-term to lifelong treatment with PPI.

Peptic ulcer disease

Peptic ulcer disease usually occurs in the stomach and proximal duodenum. It is caused by infection with Helicobacter pylori bacteria and use of nonsteroidal anti-inflammatory drugs (NSAID).

Short-term PPI use for treatment of peptic ulcer disease is recommended for two to 12 weeks, unless maintenance therapy is clearly indicated, such as ongoing NSAID use.

If PPI is so effective then what is the problem. The problem is, and the studies have shown, once a patient is started on PPI, the symptoms are not reviewed and patients stay on them for years with no valid indication.

Long-term use of PPIs is not without risks, including vitamin B12 deficiency, osteoporosis, pneumonia and C. difficile associated diarrhea (colitis). A recent study suggests that the heartburn drugs may be associated with an increased risk of dementia and kidney disease.

What should patients and health care providers do?

There is an interesting website ( that helps patients understand the rationale for deprescribing certain medications.

If the decision is made to deprescribe, the key to success is monitoring for rebound hyperacidity. Regular follow-up over the following four to 12 weeks is critical to assess for and manage adverse symptoms to deprescribing PPIs.

An article on the Mayo Clinic website by Avinash K. Nehra, MD et al titled “Proton Pump Inhibitors: Review of Emerging Concerns,” says that based on current recommendations, the American Gastroenterological Association does not recommend routine laboratory monitoring or use of supplemental calcium, vitamin B12, and magnesium in patients taking PPIs daily.

Nehra’s current practice is to check creatinine levels yearly, complete blood cell counts every other year, and vitamin B12 levels every five years in patients receiving long-term PPI therapy.

In summary, the best strategy is to prescribe PPIs at the lowest dose on a short-term basis when appropriately indicated so that the potential benefits outweigh any adverse effects associated with the use of PPIs, says Nehra.

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Heartburn is the Most Common Gastric and Intestinal Symptom Seen by Family Physicians

Looking for something deer? (Dr. Noorali Bharwani)
Looking for something deer? (Dr. Noorali Bharwani)

Heartburn is due to the reflux of stomach acid and food into the esophagus, the throat, or the lungs. It is the most common gastric and intestinal disorder seen by family physicians. The condition is also known as gastroesophageal reflux disease (GERD).

Occasionally, patients with gastric reflux may present with chest pain. It is not a good idea to tell a patient with a history of reflux that the chest pain is due to GERD. It is imperative that the patient should be first investigated for a heart condition. If that is normal then the patient should be investigated for GERD.

Some patients with GERD may present with symptoms of chronic cough, asthma and laryngitis. Other atypical symptoms include dyspepsia, upper abdominal pain, nausea, bloating and belching, though these are symptoms also seen in other conditions. So each patient should be evaluated carefully.

Most patients with GERD are in the age group 70 to 79 years. Lowest incidence of GERD is in the age group 20 to 29. As the person ages the frequency and duration of esophageal acid exposure, and severity of esophagitis (inflammation of the esophagus) increases.

There are many reasons why GERD symptoms get worse. Some medications and posture may aggravate the symptoms. Obesity is a major risk factor for acid damage to the esophagus. Patient should be immediately investigated with endoscopy (scope test) if there is a history of weight loss, difficult or painful swallowing or there is presence of anemia.

Endoscopic examine of the esophagus, stomach and duodenum is a good diagnostic test for patients with a history of reflux. Patients with uncomplicated reflux may not need a scope test unless the diagnosis is not clear. But patients with complicated reflux should be scoped.

Treatment of reflux is mostly medical. Start with lifestyle changes. Avoid food that gives you heartburn. Lose some weight. Weight loss has been shown to be beneficial in patients who are overweight.

Elevation of the head of the bed and avoidance of late evening meals, particularly with high fat content, has shown to be beneficial for individuals with nocturnal symptoms or sleep disturbance.

Avoidance of food triggers such as chocolate, caffeine, citrus foods, spicy foods, carbonated beverages, etc., has been shown to be beneficial only if an individual can identify a specific trigger.

If a patient presents with typical symptoms of GERD then a trial of medication is indicated. Most commonly used pills fall under the category of proton pump inhibitors (PPI). Some examples of PPI are pantoprazole (Tecta, Pantoloc), omeprazole (Losec), lansoprazole (Prevacid), rabeprazole (Pariet). There are no clear differences between PPIs in terms of symptom relief or healing of inflamed esophagus (erosive esophagitis).

For best effect, PPI should be taken 30-60 minutes before the first meal of the day. Symptoms more likely to respond to PPI therapy include upper abdominal pain, early sense of fullness and belching. Antacids have a relatively short duration of action and their use can be associated with significant side effects.

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Surgery Is An Option For Individuals With Intractable Heartburn

A young man suffering from chest pain. (Hemera/Thinkstock)
A young man suffering from chest pain. (Hemera/Thinkstock)

Heartburn afflicts nearly two thirds of adults at some point in their lives, and accounts for millions of physician office visits every year. That adds up to a lot of tax dollars.

Last week we discussed the various aspects of medical treatment for heartburn, also known as gastroesophageal reflux disease (GERD).

There is a small group of patients with GERD who do not respond to medical treatment and they wonder if there is another option to relieve the symptoms and complications. Surgery, of course, is an option. Surgery is also an option for those who do respond to pills but cannot afford to buy them or do not want to be on the pills for the rest of their lives.

In GERD, there is failure of the antireflux barrier, allowing abnormal reflux of stomach contents into the esophagus. It is a mechanical disorder, which is caused by a defective lower esophageal sphincter (valve) at the junction of the esophagus and stomach, a gastric emptying disorder, or failed esophageal peristalsis. But the exact nature of the antireflux barrier is incompletely understood.

Surgery should not be considered without objective evidence of reflux. Based on the available evidence, the diagnosis of GERD can be confirmed if at least one of the following conditions exists: a mucosal break (inflammation and ulceration) seen on endoscopy in a patient with typical symptoms, Barrett’s esophagus on biopsy (considered to be a premalignant condition), a peptic stricture (narrowing due to chronic ulcer) in the absence of malignancy, or positive pH-metry (checks for the presence of acid reflux in the esophagus).

Clinical Guidelines published in 2010 by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) makes the following recommendation regarding surgical management of GERD:

“Surgical therapy for GERD is an equally effective alternative to medical therapy and should be offered to appropriately selected patients by appropriately skilled surgeons. Surgical therapy effectively addresses the mechanical issues associated with the disease and results in long-term patient satisfaction. For surgery to compete with medical treatment, it has to be associated with minimal morbidity and cost.”

The antireflux surgery is done laparoscopically or by open method by surgeons thoroughly trained in this technique. Laparoscopic technique requires a short hospital stay and early return to work compared to open technique which requires a long abdominal incision and longer hospital stay with about six weeks of post op recovery. The two approaches have been demonstrated to have similar postoperative outcomes at the reported follow-up intervals (range three to 24 months) including reflux recurrence, dysphagia (difficulty swallowing), bloating, and reoperation rates.

SAGES recommendation says laparoscopic fundoplication should be preferred over its open alternative as it is associated with superior early outcomes (shorter hospital stay and return to normal activities, and fewer complications) and no significant differences in late outcomes (failure rates). If you are referred to a surgeon for this procedure then you should carefully discuss pros and cons of medical vs. surgical treatment. Your case may be different than your neighbour’s. What is good for your neighbour may not be good for you.

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Medical Treatment of Heartburn is Not Always Satisfactory

Heartburn (Hemera)
Heartburn (Hemera)

In the last column, we discussed the long term consequences of untreated heartburn. Also known as gastroesophageal reflux disease (GERD). But, you may ask, “Doctor, is there a satisfactory medical treatment for this problem?”

There are three main goals to achieve when treating GERD: symptom control, the healing of the damaged esophagus (reflux esophagitis) and prevention of complications like stricture (narrowing) and cancer.

For the most part patient satisfaction is achieved by symptom control. First by lifestyle change: losing weight, eating small meals, avoid food which triggers heartburn, avoid bending, maintain good posture, no smoking, no alcohol, and the most important is to keep the head end of the bed elevated at night.

Quite often patients treat themselves with the help of antacids. Antacids can be bought over-the-counter (Maalox, Diovol Tums, Rolaids and others). Antacids neutralize excess stomach acid to relieve heartburn. Some antacids also contain simethicone, an ingredient that helps eliminate excess gas. Antacids do not heal ulcers. They provide temporary symptomatic relief.

Some antacids contain magnesium or sodium bicarbonate, ingredients that may have a laxative effect. Overuse of antacids can result in constipation, diarrhea, white or pale bowel movements and stomach cramps.

The next line of treatment is the use of pills called histamine H2-blockers (Pepcid, Tagamet, Zantac 75, and Axid). Some of these are available over-the-counter. These medicines reduce the production of stomach acid; treat stomach or duodenal ulcers, esophagitis, and GERD.

The side effects of histamine H2-blockers are not very common, but may cause confusion, chest tightness, bleeding, sore throat, fever, irregular heartbeat, weakness, and unusual fatigue. Other less serious side effects include headache, dizziness, and diarrhea, which are usually temporary and will likely go away on their own.

Proton pump inhibitors (PPIs) are the most advanced level of medications so far for treating GERD. PPIs reduce release of stomach acid by blocking a membrane protein called a proton pump. PPIs available in Canada include: esomeprazole (Nexium), lansoprazole (Prevacid), omeprazole (Losec), pantoprazole (Pantoloc), rabeprazole (Pariet).

PPIs can provide resolution of heartburn. PPI does not fix the primary problem which is the incompetent valve at the junction of the stomach and esophagus. So, you have to take the pills on a regular basis to relieve the symptoms.

The typical side effects of PPIs may include abdominal pain, nausea, diarrhea, headache, dizziness, and itching. PPIs have the potential to interact with some other medications. If you are taking medications other than a PPI, be sure that your doctor and pharmacist are aware.

If you are not responding to the above medications then your doctor may decide to add a promotility agent (prokinetic drugs). Promotility drugs enhance the emptying of the stomach and/or gut and enhance the contractions/co-ordination of the gut. It will make you pass lot of gas. Make sure you look over your shoulder before you let it out. You don’t want your mother-in-law behind you. If your wife is behind you then you are dead.

Commonly used promotility drugs are: domperidone (Motilium), metoclopromide (Reglan, Maxeran). These pills block the dopamine receptors in the brain and the stomach. Blocking dopamine can also have an effect on increased prolactin secretions. Prolactin is a hormone which increases milk supply in the breasts – milk leakage (galactorrhea), may be a problem.

Other side effects of promotility drugs are bothersome central nervous system side effects – depression, an overall feeling of restlessness, restless legs (akathisia), tremors and rigidity (Parkinsonism), and insomnia. One very serious side effect is called tardive dyskinesia (tardive meaning late onset, and dyskinesia meaning abnormal muscle movements).

If none of the above treatment works for you or you have complications related to esophagitis then surgery is an option. Stay tuned.

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