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A lady sent me a distressing message. It said: 

Krishna Madam, I am in distress and I hope you would be able to help me. I have GERD. My doctor prescribed Somprez D40. I have been taking these capsules for the past six months. But my reflux still continues although the burning sensation subsided. I heard there will be several side effects for the medicines I am taking. So  I tried to discontinue the medicine but am facing severe acid rebound problem. It is like drinking acid! It burns my GI tract so much. My doctor is asking me to continue with the medicine which I don't want to do. He says he had seen people using it for more than 10 years! What should  I do? I am in pain. Please help me. 

Krishna: Sorry to hear about your condition.

Gastroesophageal reflux disease or GERD is  a digestive disorder.  It occurs  when stomach acid frequently flows back into the tube connecting your mouth and stomach (esophagus). This backwash (acid reflux) can irritate the lining of your esophagus.

Many people experience acid reflux from time to time. GERD is mild acid reflux that occurs at least twice a week, or moderate to severe acid reflux that occurs at least once a week.

Common signs and symptoms of GERD include a burning sensation in your chest (heartburn), usually after eating, which might be worse at night, chest pain, difficulty swallowing, regurgitation of food or sour liquid, sensation of a lump in your throat. You might also experience, chronic cough, laryngitis, new or worsening asthma, disrupted sleep.

When you swallow, a circular band of muscle around the bottom of your esophagus (lower esophageal sphincter or LES) relaxes to allow food and liquid to flow into your stomach. Then the sphincter closes again.

If the sphincter relaxes abnormally or weakens, stomach acid can flow back up into your esophagus. This constant backwash of acid irritates the lining of your esophagus, often causing it to become inflamed.

Conditions that can increase your risk of GERD include obesity, bulging of the top of the stomach up into the diaphragm (hiatal hernia), pregnancy, connective tissue disorders, such as scleroderma*, delayed stomach emptying. And factors that can aggravate acid reflux include smoking, eating large meals or eating late at night, eating certain foods (triggers) such as fatty or fried foods, spices, onions, citrus fruits, tomatoes, and chocolate, drinking certain beverages, such as alcohol or coffee, taking certain medications, such as aspirin and stress. 

Instead of tackling the real  problem,  some doctors prescribe  medicines that suppress acid production like PPIs or proton pump inhibitors like Somprez D40.

Long term or large dosage use of PPIs 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.
  • Increased risk of pneumonia.
  • Bacterial infections introduced through foods.
  • Increased risk of a Clostridium difficile infection.
  • Decreased absorption of vitamin B12, calcium, magnesium, iron and other nutrients leading to bone fractures, hypomagnesemia, and cardiac arrhythmias.
  • 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.
  • Increased risk of esophageal cancer.
  • Increased risk of chronic kidney disease
  • Increased risk of liver damage
  • Increased risk of stomach cancer
  • Increased mortality risk
  • Dry mouth

The FDA (US) says PPIs should not be used for more than four months especially for GERD symptoms! 

So your decision to quit after six months of taking the medicine is correct. 

However, there will be severe problems for some people (about 44% of them, according to some studies) while quitting. These problems can last from three weeks to three months. These people go back to the PPIs again when they are unable to overcome acid rebound and get addicted to them. To effectively tackle these problems, you have to understand how PPIs work in the first place.

PPIs are needed to treat ulcers, acid damage, Helicobacter pylori, or other condition where PPIs are neccessary. 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 are one of the many who’ve been overprescribed PPIs, symptom control may be achieved at a lower dosage, frequency, or even with a less potent form heartburn medication like an H2 blocker.

It is important 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. 

    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’re weaning off PPIs. Many are fortunate and can easily lower PPI dosages. Others are not as fortunate. Weaning off PPIs is not possible for those whose disease has progressed too far. These people will have to stay on PPIs. Remember PPIs do not cure GERD. They only mask the pain. GERD 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 well-being 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 symptoms 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 an endoscopy performed proving erosive esophagitis or a positive pH test. Weaning off PPIs will be easiest for those who were misdiagnosed.

    Let us now understand why you face the problems of acid rebound.

    PPIs block acid secretion in the acid-producing parietal cell in the stomach. The decreased acid causes endocrine cells in the stomach to secrete a hormone called gastrin. This signals to the parietal cell that more acid is needed in the stomach, which is normally produced during a meal when the food neutralizes gastric acid. In a person taking PPIs, the gastrin has no effect and continues to increase in the blood. When the PPI is withdrawn, the elevated gastrin causes a rebound increase in acid secretion. When reflux occurs, it is like drinking acid and it burns your oesophagus and  throat severely as they do not have protective lining against acid. Weaning off becomes difficult, you start taking the PPIs again and you are likely to get addicted to them. Acid rebound might be  temporary and adjusts quickly (within a week or two or three) as the normal balance between acid production and gastrin production is restored. Meanwhile you have to bear the pain and burning sensation or manage them in a better way if you don't want to become an abuser of PPIs. 

    It is during this period that some people face hell. The excess production of acid because of gastrin makes life very difficult. To control this problem, you have to follow these steps...

    1. 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 you wean off PPIs the less likelihood of acid rebound.
    2. Once you are 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 PPI 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 an H2 blocker where you once took the PPI.
    3. Step down to the use of an 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.
    4. At this point, you should be able to treat the occasional heartburn on demand with antacids or with antacids and H2 blockers when necessary.
    5. Once you have weaned off the H2 blocker you may find you have no need for the mucilage*. You can stop taking it or wean off of it as well.

    Experts say you should also follow these things:

    1. 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. Heartburn 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 weight 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 overeat 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 the head of your bed or by 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 and 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.
    2. Replace
    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. Stomach acid aids in the proper function of the LES, breaks down food, and stimulates digestion. Avoid any betaine hydrochloride supplement containing NSAIDs or steroids. They can damage or irritate the digestive lining.
    3. Repopulate
    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 nondigestible carbohydrates 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.
    4. Repair. Mucilage is a thick, gluey substance found in plants that help 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 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. Aloe vera can be purchased in a number of forms: juice, gel, powder, softgels, and capsules. 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.
    5. Rebalance
    Decrease stress: Stress can increase sensitivity to acid and should be managed through exercise, enjoyable activities, soothing music, meditation,  massage, pets, friends, laughter, sleep, etc.
    Exercise: Make sure you’re performing exercises that reduce heartburn risk and wait two or more hours after eating to avoid added pressure on the LES.

    So don’t panic after hearing about the side effects or when you face them personally and rush the process when weaning off PPIs. Remember, the longer you have taken them, the more you get addicted to them and the longer you will want to take when weaning off to prevent an overproduction of acid. We are all different so consult your doctor before weaning off PPIs. 

    Well, understanding the science behind any health issue helps you to manage it in a much better way. Hope my article helps you in that direction.

    Please let me know and wishing you a speedy recovery ... K

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https://blogs.scientificamerican.com/observations/is-addiction-a-di...

* Scleroderma, or systemic sclerosis, is a chronic connective tissue disease generally classified as one of the autoimmune rheumatic diseases. The word “scleroderma” comes from two Greek words: “sclero” meaning hard, and “derma” meaning skin. Hardening of the skin is one of the most visible manifestations of the disease.

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