In the mid-1990s, during my medical school physiology class, I discovered a remarkable drug designed for acid reflux treatment. This medication, known as Nexium, was the most effective method available for reducing stomach acid by permanently binding to proton pumps—cells responsible for acid secretion in the stomach lining. Nexium was the first of a new class of medications called proton pump inhibitors (PPIs), which significantly changed the landscape of treating digestive issues.

Previously, H2 blockers like Tagamet and Pepcid were the go-to medications for acid reflux. While they effectively managed the aftermath of indulgent meals, they only provided temporary relief by lowering acid production. Some individuals, however, required complete suppression of acid production due to severe conditions such as Barrett’s esophagus—which can lead to cancer—and gastritis, which can result in bleeding ulcers. Nexium emerged to meet this need, and today, there are eight different brand-name PPIs available in the U.S. For numerous patients, these medications have been, and continue to be, crucial for their health.

By 2009, CNN reported that PPIs ranked as the third most prescribed medication in the United States, with 110 million prescriptions and sales reaching $13.6 billion. By 2013, spending on brand-name Nexium alone eclipsed all other medications covered by Medicare Part D. Along with its generic counterpart, omeprazole, it became the most prescribed drug for Medicare beneficiaries. By 2017, Nexium was recognized as one of the best-selling drugs in history.

However, around 2010, healthcare providers and researchers began to observe adverse effects in patients using PPIs over extended periods. Long-term use—typically defined as exceeding 6 to 12 months—often led to increased incidents of bacterial gut infections, including Salmonella, Campylobacter, and Clostridium difficile, along with higher rates of pneumonia. Additionally, patients experienced more bone fractures and difficulties absorbing magnesium and Vitamin B12. A 2018 review by the Mayo Clinic validated these concerns, adding chronic kidney disease and dementia to the list of potential complications—an ironic twist, given that many recipients of these drugs are over 65, a demographic already vulnerable to these conditions.

As of July 2022, over 13,000 lawsuits related to PPIs were pending in federal courts.

Why, then, does prolonged suppression of stomach acid lead to so many complications if acid reflux is such a significant issue?

The reality is that stomach acid is essential for our bodies. It plays a crucial role in breaking down food and absorbing vital nutrients, including proteins, vitamins, and minerals. Additionally, stomach acid acts as a barrier against infections by eliminating harmful bacteria and viruses. A medical condition known as hypochlorhydria, characterized by insufficient stomach acid production, has been linked to a variety of health issues, including autoimmune disorders, allergies, eczema, and thyroid dysfunction.

So why is there such a high prevalence of PPI prescriptions? The reasons are multifaceted, and I invite readers to share their thoughts and insights in the comments for a robust discussion.

(Note: This article aims to provide general information for those experiencing mild acid reflux. It does not encompass the needs of individuals with conditions requiring PPI use, for whom these medications can be lifesaving.)

1. Overprescription The pharmaceutical industry has a history of encouraging physicians to prescribe costly medications. In the past, this often involved lavish dinners and sponsored trips to win over doctors. While such practices have diminished, the normalization of PPI prescriptions as a primary treatment for acid reflux continues. Many patients are placed on PPIs without a clear plan for discontinuation. Even newborns are frequently prescribed PPIs for issues like colic and spitting up, despite the lack of supporting evidence for their effectiveness.

2. Direct-to-Consumer Marketing Historically, medications required a doctor's prescription, as they were responsible for diagnosing ailments and recommending treatments. In recent decades, however, drugs have increasingly been advertised directly to consumers. This practice raises questions about whether the intent is to inform or mislead. PPI commercials often appear alongside food advertisements, possibly suggesting a connection. Consequently, patients frequently enter consultations requesting specific medications based on these ads.

3. Misdiagnosis or Self-Diagnosis Warnings about stomach acid are prevalent, with some sources suggesting that it poses significant health risks. A condition known as silent reflux can cause symptoms such as coughing without the presence of heartburn. I find many of these diagnoses questionable, as I've seen success treating these symptoms by addressing underlying issues rather than prescribing PPIs. Many individuals mistakenly believe they have acid reflux, influenced by misleading information.

4. Ease of Over-the-Counter Access After a drug is developed, it typically receives patent protection, allowing the manufacturer to recoup development costs. Once this patent expires, the drug can be sold generically and often becomes available over the counter (OTC). Nexium became available OTC in 2014, allowing easy access without a prescription. Other PPIs like Prilosec and Prevacid are also available in this manner. While there are recommendations to limit their use to two-week intervals, there is no monitoring or regulation, leading many to incorrectly assume that OTC medications are entirely safe.

5. Addressing Symptoms Rather Than Causes Various factors can contribute to stomach discomfort and heartburn. While we’re often advised to avoid “acidic foods,” many individuals lack knowledge about which foods truly fit that description. For example, soft drinks like Coke have a pH of 2.6 to 2.7, making them highly acidic. Additionally, foods that aren't acidic can still cause inflammation. Dairy can lead to symptoms resembling acid reflux due to lactose intolerance, while gluten can have similar effects. I intend to delve deeper into gut inflammation in a future article, but it’s essential to understand that not all marketed food is beneficial, and much of our diet is engineered to be appealing rather than nutritious.

Many individuals experience yeast overgrowth in their digestive systems. I've successfully implemented medically designed food cleanses for patients, alleviating their acid reflux symptoms without the need for PPIs.

Ultimately, while it's convenient to take medication for acid reflux, a better approach would be to investigate how dietary choices impact our symptoms. Keeping a food journal can be an insightful first step in this process.

What steps can you take? If you've been on PPIs for an extended period, discontinuing them abruptly is not advisable. Since PPIs bind permanently to proton pumps, tapering off gradually is essential. In the interim, you might consider switching to a milder option like an H2 blocker or TUMS. Collaborating with a nutritionist or physician can help ensure you make informed choices regarding your health.