by Dr. Leo Galland
Sometimes a small part of a problem offers a window into the heart of that problem.
A recent issue of the Archives of Internal Medicine, published by the American Medical Association, did just that by focusing attention on the side effects of drugs used to suppress stomach acid. There are several ways in which the overuse of these drugs tells us why American health care is in a state of crisis.
The five research papers in the Archives highlight the major side effects of using acid-suppressing drugs, something that I have been calling attention to in my writing.
The papers find what previous studies have found: people using common drugs that suppress stomach acid have an increased risk of fractures, serious intestinal infections and pneumonia.
The accompanying editorials use this example to make a larger point about healthcare.
Dr. Mitchell Katz of the San Francisco’s Department of Public Health states that most people taking acid suppressive drugs would be better off without them.
Drs. Deborah Grady and Rita Redberg of the University of California at San Francisco kick off a new series in the journal called “Less is More: How Less Health Care Can Result in Better Health.”
Does this represent a sea change in the practice of medicine? Probably not.
But it does bring to light the limitations of conventional medicine and its over-reliance on medical technologies, including medication. The prescription of drugs that suppress stomach acid is an excellent lens for viewing that problem.
Drugs called proton pump inhibitors (PPIs), of which Prilosec (omeprazole) was first on the market, are the third most highly prescribed class of drugs in the U.S.
There were 113.4 million prescriptions written for PPIs last year, accounting for sales of $13.9 billion. Less than 10% of these prescriptions were for conditions that have been proven to require these drugs for treatment, and the majority of prescriptions were written for reasons deemed inappropriate by medical researchers.
These data do not even include the widespread used of non-prescription acid blockers. Omeprazole is now available over the counter, along with milder acid-suppressors called H-2 blockers, a class which includes familiar names like Zantac and Pepcid. Research has found that H-2 blockers create the same problems as PPIs, only milder, presumably because they are less effective at reducing stomach acid.
Here are some insights from examining the debacle of PPIs and H2 blockers:
(1) Acid suppression is part of a therapeutic approach that relies on inhibition of normal physiology to relieve symptoms, and most of its adverse effects result from that suppression. With one rare exception, none of the disorders for which these drugs are used results from excess secretion of stomach acid. They all result from normal amounts of acid irritating sensitive tissues, unless you’ve been taking acid suppressors for several weeks and try to stop them, in which case your stomach begins secreting higher levels of acid than it did before you took the drugs. A study of healthy asymptomatic people who took omeprazole daily for six weeks found that thirty percent of people who never had heartburn developed heartburn after stopping the drug. Most drugs, in fact, work by suppressing normal cellular function, which is why most drug classes have names that include “blocker” or “inhibitor” and most drug side effects are a direct extension of the drug’s therapeutic actions. It’s easy to see why less rather than more might be better for your health.
(2) Useful but costly technologies become overused because they substitute for real problem solving. A study conducted by Harvard researchers some years ago asked a sample of doctors how they would treat a new patient with abdominal pain who had previously been given a diagnosis of gastritis (stomach inflammation) and a prescription for an acid-suppressing drug by another physician. Sixty-five percent were ready to prescribe an acid-suppressor and half of those did not even inquire about use of aspirin, alcohol, cigarettes, or coffee, each of which could be the primary cause of the patient’s symptoms. The nurses in that study did much better than the doctors, suggesting that doctors might benefit from the kind of person-oriented training that nurses are more likely to receive.
(3) “Competition” is manipulated to raise prices rather than reduce them. Each new acid suppressor is followed by copycat drugs, alleged to be stronger, more effective or easier to use. Among PPIs, the copycat list includes familiar names like Nexium, Prevacid, Zegarid, Aciphex, and Protonix. Even when controlled studies have failed to authenticate claims of superior therapeutic outcomes for the newer drugs each new product is often more expensive than the previous one, and when the newer, costlier product is released, the price of the older products often go up.
(4) Simple, more physiological treatments are often ignored or misunderstood. The most common condition for which acid-suppressing drugs are used today is gastroesophageal reflux (GERD), the regurgitation of stomach contents into the esophagus. Acid reflux can produce heartburn, burping, sore throat, cough, and other symptoms, may cause serious disorders like esophageal ulceration or asthma and probably contributes to the development of one type of esophageal cancer. PPIs don’t prevent or reverse reflux. They convert acid reflux to non-acid reflux, which may be less irritating. There are two inexpensive over-the-counter products that actually prevent reflux without reducing stomach acid: calcium and melatonin. Most people think of chewable calcium pills like Tums and Rolaids as antacids. They are actually very weak antacids with no significant effect on levels of stomach acid. The real benefit of calcium is that it improves function of the lower esophagus, helping it to expel refluxed material back into the stomach and tightening the LES valve, which separates esophagus from stomach. Calcium pills swallowed whole don’t do this. The calcium must make contact with the esophageal lining, so it’s best taken as a chewable tablet or liquid suspension.
Melatonin, a hormone produced in response to darkness by the pineal gland at the base of the brain, is available in this country as a dietary supplement. Most people think of melatonin as a sleep aid, but it has profound effects on the digestive tract. Recent studies have shown that melatonin not only relieves symptoms like heartburn but also prevents reflux by tightening the LES valve, an effect that PPIs do not have. Of interest, patients with gastroesophageal reflux had lower levels of melatonin than people without reflux, so melatonin might be treating an underlying condition, perhaps related to light pollution in urban environments.
The example of acid suppression therapy, with its direct and indirect costs, suggests some strategies through which American health care can improve outcomes and reduce costs by educating physicians and consumers.
The “Less is More” series in the Archives is a welcome start.