Combating GERD: Are PPIs the Answer?

Welcome to The Perfect Stool: Understanding and Healing the Gut Microbiome. This is your host, Lindsey Parsons, and today I'm going to be talking about proton pump inhibitors, or acid-reducing medications, also known as PPIs, why they're prescribed, and how to avoid taking them. But before I dig in, if you haven't yet followed or subscribed to the show, please be sure to do so. And if you want to get transcripts of the podcast, pop over to to my website, HighDesertHealthCoaching.com, and sign up for my newsletter. You'll also get my free ebooklet called Finding Your Root Cause Through Stool and Organic Acids Testing when you sign up. And if you haven't yet done my quiz on which stool test would help you get to your root cause, you can find a link in the show notes and take that. Now onto the show. So you may have heard the term PPI being thrown around. It stands for proton pump inhibitor, which is one of the most commonly prescribed and taken medications in the US, primarily for acid reflux or GERD, G-E-R-D, that is gastroesophageal reflux disease, with 15 million Americans a year using them. Some examples of PPIs are Nexium, Protonix, Aciphex, omeprazole, Prilosec, and Prevacid. And they've been available over the counter in the US since the early 2000s. And as a result, many people think they're safe, and a viable long-term solution for acid reflux, despite having a strong warning on the package to not use them for more than 2 weeks straight. In addition to their use for GERD, PPIs are also prescribed for ulcers, gastritis, and Zollinger-Ellison syndrome. So I'm going to dig in a little bit more on each of those conditions, their root causes, and then, you know, the alternative treatments and the long-term drawbacks of PPI usage, so you can investigate those other alternatives. So let's start with what GERD is. The most common reason your doctor may prescribe or recommend a PPI is GERD, or acid reflux, which affects between 18 and 28% of Americans and over 20% of people in the Western world. Gastroesophageal reflux occurs when the lower esophageal sphincter lets acid up into the esophagus. Common symptoms of that are trouble swallowing, heartburn, a foul or acrid taste in your mouth, regurgitating food, although what I used to get when I had GERD was just little tiny bits of food in my mouth in the morning, indicating that, that some acid had been coming up during the night, upper abdominal chest pain, sore throat, and vomiting. Well, after a particularly big or unhealthy meal, anyone may have those types of symptoms. If they're happening on a regular basis, you may have GERD. Then there's another type of GERD called LPR, or laryngopharyngeal reflux, which is the type I had. For me, its main manifestation was a chronic cough, usually worst in the 30 to 60 minutes after I ate, a feeling of warmth and sometimes hunger, and about an hour after eating in my chest, postnasal drip, frequent throat clearing, hoarseness, and a lump and mucus in my throat. Other symptoms can include persistent irritation of the throat, the vocal cords, respiratory problems, and plugged eustachian tubes, which connect your middle ear to the back of your nose and throat. So this was the condition I was dealing with when my doctors first suggested PPIs to me. I subsequently took them for about 10 to 15 years, which may have contributed to my other issues that arose after that, including multiple autoimmune diseases. I've since learned that meta-analyses of PPIs for LPR have shown they're no better than a placebo. So anyone can develop GERD or LPR, but some are more at risk than others. You're most likely to develop GERD if you're overweight, taking medications that cause acid reflux, pregnant, smoking regularly, drinking alcohol regularly, have an autoimmune disease called scleroderma, or have a hiatal hernia, which is when the upper part of the stomach bulges into the diaphragm. Left unaddressed, GERD is not life-threatening on its own, but long-term and left untreated, GERD can lead to serious health issues like esophageal cancer, not to mention the discomfort you're dealing with during all that time. So while the kinds of recommendations my doctor made to me about not going to bed until 2 hours after a meal, or putting the head of your bed up on blocks to sleep at an angle, or even sleeping in a recliner may have been well-intentioned, they never got at the root cause of my reflux. So the question is, is GERD always caused by high stomach acid? When doctors recommend PPIs for GERD, their assumption is that you have too much stomach acid. But one of my former podcast guests, professor of naturopathic gastroenterology and author of a textbook on functional gastroenterology, Dr. Steven Sandberg Lewis, he, he performs a test in his office, which is the gold standard test for stomach acid called Heidelberg test, with his patients. And over the years, he's found that 75% of them actually have low stomach acid or hypochlorhydria, and only 25% of them have excess stomach acid. In addition, some of them have hidden hypochlorhydria, which means they have some normal stomach acid on the first challenge, but it runs out after a while, meaning there's just not enough of it to digest a meal. And while most people won't have access to this test to determine officially whether they have too much or too little stomach acid, there are a couple easy ways to determine what's likely. One way is by taking a capsule of betaine HCl, or just substitute hydrochloric acid or stomach acid, halfway through the meal with 6 ounces of animal protein, because you only need the betaine HCl if you're eating animal protein. And if you feel burning or warmth in your chest, you probably have adequate stomach acid. But you should be sure to check at a few different meals to be sure. You can always neutralize acid with Tums or a little baking soda and water if the burning is uncomfortable. Now, if you don't have those sensations, then you may be deficient in stomach acid. Other clues that you may have low stomach acid can be found on your standard blood tests called the CMP, or comprehensive metabolic panel, and CBC, or complete blood count. So if you have one or more of these signs—chloride levels under 100, high or low serum protein or serum globulin levels, low phosphorus levels, especially with a vitamin D deficiency, high BUN levels— that's BUN— of 20 or more, abnormal MCV, MCH, MCHC, or below normal hematocrit or hemoglobin indicative of iron deficiency. All those may be signs that you may have low stomach acid. And then there are several common reasons you may be low on stomach acid that you may already know about, including having had gastric surgery, having stomach cancer, or having autoimmune gastritis, which is an autoimmune attack on the parietal cells in your stomach that produce acid and intrinsic factor, which help us absorb vitamin B12, which is— which causes pernicious anemia, which is a deficiency of B12. So if you've been diagnosed with a B12 deficiency, that's a good sign already that you might be deficient. I was diagnosed with that issue early on in my gut health journey, but no one suggested at that point that I may need to support my stomach acid production. Since autoimmune diseases tend to occur in groups, if you have another autoimmune disease, it's also possible you have autoimmune gastritis as well, and you can ask to have your parietal cell and intrinsic factor antibodies tested to check for it. Finally, if you have H. pylori or Helicobacter pylori, which is a bacteria, you may have low stomach acid. I'll dig into that a little bit more in a bit. Another sign for me is when my clients tell me that when they eat meat, it just feels like it sits in their stomach. They And also sulfur smelling gas is also a possible sign of undigested protein and low stomach acid. And of course GERD isn't always related to stomach acid, but can be the result of upward pressure from gases from an excess of bacteria in your small intestine, or small intestine bacterial overgrowth, or SIBO, and undigested or malabsorbed carbohydrates. In my case, the carbohydrates that weren't being absorbed were from dairy. I realized I had an intolerance to dairy, in particular casein in dairy, which seemed to be at the root of my acid reflux, as it disappeared almost completely after I eliminated dairy from my diet. I already knew I was lactose intolerant, and I was taking the lactase enzymes when eating dairy, and had— I'd already removed gluten from my diet, but the complete removal of dairy was key for me personally in getting rid of acid reflux. For those people who do actually have excess stomach acid, one reason is a condition called Zollinger-Ellison syndrome, which is a rare digestive disorder that causes tumors called gastronomas in the intestine, pancreas, or both. And those gastronomas release the hormone gastrin, which prompts the stomach to produce too much acid. That's one of the reasons why it's best to start to try to address these types of issues with a gastroenterologist to make sure it's not something serious. And if you get nowhere with that approach or you get a clean bill of health, then a functional medicine or naturopathic expert on gut issues may be in order. Another common cause of excess stomach acid is an H. pylori infection, and usually with a new infection, stomach acid increases, but then after the infection continues and expands, the damage to the stomach cells can lead to low stomach acid. This is caused by the release of an enzyme from H. pylori called urease, which breaks down in the stomach into carbon dioxide and ammonia, causing burping and bad breath that are commonly associated with H. pylori, and neutralizes stomach acid. You can also end up with excess stomach acid after going off a PPI or H2 blocker. Common H2 blockers are famotidine, like Pepcid AC, Pepcid Oral, Zantac 360, Cimetidine, which includes Tagamet and Tagamet HB, and nizatidine capsules like Axid AR and Axid capsules. And then a couple other less common reasons for high stomach acid include gastric outlet obstruction and chronic kidney failure. So in addition to their use in GERD, PPIs are often also prescribed to both prevent and treat ulcers, which are open sores on the inside of your stomach, also known as a gastric ulcer. Or an open sore on the inside of the upper portion of your small intestine or your duodenum, AKA a duodenal ulcer. Together, both are referred to as peptic ulcers, and symptoms of ulcers include burning stomach pain, a feeling of fullness, bloating or belching, intolerance to fatty foods, heartburn, and nausea. And some more severe but less common symptoms are vomiting or vomiting blood, which may appear red or black, dark blood and stools, or stools that are black and tarry, trouble breathing, feeling faint, unexplained weight loss, and appetite changes. Because the main causes of ulcers are H. pylori and long-term use of NSAIDs, or nonsteroidal anti-inflammatory drugs, and/or taking other medications along with NSAIDs, such as steroids, anticoagulants, or SSRIs, which are selective serotonin reuptake inhibitors, which are prescribed for anxiety or depression, or the drugs Fosamax or Actonel, getting off of those medications through functional medicine approaches to the issues necessitating them is a necessary first step. And then for H. pylori, getting diagnosed and treating it. However, in the meantime, if you do have an active ulcer, taking a PPI is recommended and can prevent further damage and serious complications while it's healing and you're removing the root cause. So what is H. pylori in more detail, and how do you know if you have it? So you may not be old enough to remember this, but I do. So they used to believe that spicy foods and stress caused ulcers, which we've since learned isn't exactly true. Doctors Barry J. Marshall and J. Robin Warren, Australian researchers, discovered in 1982 that H. pylori was in fact the root cause of more than 90% of duodenal ulcers and up to 80% of gastric ulcers, for which they were awarded a Nobel Prize for Physiology or Medicine in 2005 after being ridiculed and ignored by the mainstream medical establishment. The dilemma with H. pylori is that it doesn't always cause ulcers, and many people who are healthy have it in their systems with no problems. In fact, in developing countries, H. pylori is found in over 80% of people, and about 20 to 50% have it in developed countries, but only 10 to 15% of people who have H. pylori will develop peptic ulcers. The way that some strains of H. pylori cause peptic ulcers is by attaching themselves to the protective mucus coating of the stomach and duodenum and weakening it, allowing acid to reach the sensitive lining beneath it, causing an ulcer to form. Left untreated, ulcers can lead to stomach perforation and bleeding, and in extreme and untreated cases, death. Now, you should understand that only some strains of H. pylori cause ulcers or gastric cancer, but not all. So if you have it, it's important to find out whether your strain of H. pylori has virulence factors that can cause these complications. To find out, you can take the GI-MAP test, which currently costs $399 and is one of my favorite functional medicine stool tests. Or an H. pylori profile, which is the H. pylori test with virulence factors from the GI-MAP, which is just $139. You can also diagnose H. pylori, but not the strain specifically and the virulence factors through a stool antigen test, which most smart doctors will order if you request it. Although again, you often get false negatives. A urea breath test, also again, many false negatives, or a biopsy done with an, an endoscopy. However, in my experience, these biopsies always come up negative for my clients, who then test positive using the GI-MAP PCR or DNA-based test for H. pylori. And I like the GI-MAP because while it's not usually covered by insurance, the information you get on it is worth its weight in gold. You can order it yourself online too, and I usually recommend it for my clients with any chronic GI issues because it will tell you not only if you have H. pylori and whether your amount of H. pylori is abnormal and if you have virulence factors, but it will also test for all other known gut pathogens, parasites, et cetera, as well as signs of gut dysfunction originating in your digestive organs. Once you diagnose H. pylori, you can treat it either with the recommended regime of 2 antibiotics for a week plus a proton pump inhibitor. One of the rare uses for which I think a PPI is justified, or a course of herbal antimicrobials targeting H. pylori specifically, if you wanna go with a functional medicine as opposed to a conventional medicine approach. There's also a new probiotic that helps treat H. pylori called Pylorguard, which you can find in my full script dispensary. Another common reason for being prescribed a PPI is gastritis, which is inflammation, erosion, or irritation of the lining of the stomach. And that can be asymptomatic or can have symptoms such as indigestion, nausea, or recurrent stomach upset, bloating, pain, vomiting, including vomiting of blood or material that looks like coffee grounds. Burning or annoying feeling in the stomach between meals or at night, hiccups, a low appetite, or black tarry stools indicative of blood in your stool. And you can have an acute or sudden case of gastritis. So it can come on gradually for chronic gastritis and last a while, but either way, if you catch it early, gastritis can be dealt with easily. However, left untreated, it can lead to a severe loss of blood and may increase your risk of stomach cancer. So if you have evidence of blood in your stools, like the black tarry stools I mentioned, you should ask your doctor to do a fecal occult blood test. Common causes of gastritis are alcohol abuse, H. pylori, other bacterial gut infections, viral infections, and bile reflux, or when bile backflows into the stomach from the bile tract that connects to the liver and gallbladder. It's also commonly caused by aspirin and NSAID use. When I was going through terrible sciatica, I ended up taking ibuprofen at the maximum recommended dose pretty much all day long, which ended in me having either gastritis or the beginnings of an ulcer. That was one scenario where I did take a PPI for a short time in order to reduce my stomach acid and give my stomach some time to heal as I tried to find other solutions for my chronic pain. One product I can recommend if you have some type of physical pain like that, that necessitates ongoing pain relief, is called Acute Pain Relief, and you can find that in my full script dispensary. It's a Euromedica product made with curcumin and boswellia that can help your acute pain by actually decreasing inflammation in a natural manner. So while a short course of PPIs is generally considered safe, and by that, 2 weeks max, long-term PPI use is very problematic because PPIs reduce your stomach acid by up to 99%. The result of that can be the development of even worse gut bugs like C. difficile, maldigestion of protein, B12 anemia, which I had, and other vitamin and mineral deficiencies, increased risk of fractures and osteoporosis, and pneumonia. A 2021 study by Arun Koyada concluded the use of long-term PPIs may lead to significant vitamin B12 and C and mineral iron, calcium, and magnesium deficiencies, which need gastric acid for their absorption and bioavailability. So if you think of each one of those nutrients, if you're B12 deficient, you'll see signs such as fatigue or numbness in your extremities that can lead to permanent nerve damage, a sore and red tongue, mouth ulcers, disturbed vision, irritability, and depression. If you're low in calcium, this can cause muscle spasms and impair bone growth and repair and lead to osteoporosis. If you're deficient in magnesium, it can lead to heart arrhythmias, loss of appetite, fatigue, shaking, pins and needles, muscle spasms, hyperexcitability, and sleepiness. If you're deficient in iron, it can lead to extreme fatigue, weakness, pale skin, chest pain, fast heartbeat, shortness of breath, headaches, dizziness, lightheadedness, cold hands and feet, inflammation or soreness of your tongue, and brittle nails. Oh, and then of course vitamin C. If you're short on that, that's one of the most important aspects of, of a healthy immune system. Because PPIs block the production of stomach acid, which helps break proteins down into amino acids, when it's not present, it stresses the enzymatic system of the pancreas and other digestive organs, which are prompted to secrete enzymes in response to stomach acid levels and ultimately causes a decrease in the absorption of proteins. Because proteins and the amino acids that make them up are necessary for building the gut lining and pretty much any other type of cell, enzyme, hormone, or neurotransmitter in the body, protein deficiencies can lead to numerous cascading and complex medical issues and the failure to rebuild the system that is used to digest protein. These issues can include mental health issues, immune suppression, and imbalanced hormones. A 2017 study, Adverse Events of Proton Pump Inhibitors: Potential Mechanisms, concluded Current evidence suggests that use of PPIs may be associated with negative outcomes by eliciting several different pathophysiologic mechanisms. While short-term PPIs could be considered effective and safe in adult patients with acid-related disorders, their long-term and often inappropriate use in patients carrying vulnerability to adverse events and/or high risk of drug interactions should be avoided. And that hits the root of the problem. The indiscriminate prescription of PPIs when they aren't indicated medically at all which happens in 33% of cases, or outside of the current guidelines in 54% of cases. This isn't much different from the antibiotics problem where they're prescribed indiscriminately for things for which they're not indicated, because people go to the doctor with a problem that conventional Western medicine doesn't know how to solve, and the doctor feels obliged to do something, and so he or she just prescribes an antibiotic. Other serious side effects that have been linked to PPIs include dementia, kidney disease, myocardial infarction, pneumonia, and stroke. A study with US veterans found 45.2 excess deaths per 1,000 patients amongst those taking PPIs due to cardiovascular disease, kidney disease, and gastrointestinal cancer. They also found a greater number of infections, parasitic diseases, neoplasms, or newer abnormal growth of tissue in some part of the body, and genitourinary disease associated with PPI use. For kidney disease, studies consistently suggest that the use of PPIs may be associated with an increased risk of adverse kidney events, especially in the elderly with long-term PPI use and preexisting kidney disease. Another additional question being studied is whether chronic PPI use can lead to the onset of gastric cancer. The abrupt discontinuation of PPIs is also related to increased gastric acid production above PPI treatment levels, a phenomenon called acid rebound. So my advice is, if you need something to give you immediate relief from obvious acid reflux, Try a simple acid-reducing medication like Tums or baking soda and water, an H2 blocker, or if you must take a PPI, my recommendation is to follow diligently the instructions on the package that says not to take them for more than 14 days. If your problem doesn't resolve in those 14 days, you may need to look harder for your root cause. If you have follow-up questions, a great place to ask them is in my Facebook group called Gut Healing. And if you're struggling with these issues or other health issues in your gut or whole body and need some help, that's what I do for my clients. I offer free 30-minute breakthrough sessions to talk about your issues and see if gut health coaching might help you resolve them. And you can set that up by going to the link in the show notes or going to my website, HighDesertHealthCoaching.com. And if you'd like to support the show, you can make a regular donation on Patreon, buy vetted high-quality supplements from my FullScript or WellElevate dispensaries or Designs for Health dispensary, or give me a 5-star review on Apple Podcasts. Thanks for listening, and here's wishing you all the perfect stoop.