Updated: Apr 1
Some people prefer to not take medication
In the last few years more people have come to our clinic looking for ways to reduce their pain or anxiety even though they are in a difficult place that makes every day a challenge, they would prefer not to take medication, such as painkillers or antidepressants on a permanent basis. Some of you do not even want to start taking medication for your pain, hoping to find other solutions using complementary medicine, often fearful of side effects of medication or becoming reliant.
There may be reasons that over the past ten years this attitude towards medications has increased, but as I have only a small sample of the population, due to being a private practice and dealing with people who already are thinking carefully about their health and wellbeing, prompted me to investigate this movement towards a reluctance to take medications on a regular basis.
Is their attitude justified?
Two articles arrived on my computer last week, firstly Dr Peter Dingle a researcher, educator and author on healthy living from Perth, Australia; secondly an email from a manufacturer of practitioner only nutritionals that I have used for many years, both articles detailed the issues around long term use of protein pump inhibitors a popular go-to medication for indigestion, reflux and related symptoms. In recent years esomeprazole, often under the brand name of Nexium in Australia and omeprazole, you may recognise as Losec in New Zealand have changed from prescription only medication to being available over-the-counter for some strengths, thereby becoming more readily available enabling self medication for extended periods.
Both articles wrote about the safety concerns of the harmful effects of the long-term use of protein pump inhibitors (PPIs).Generally prescribed for indigestion or other digestive issues.
Reading these articles prompted me to continue to collect information about some of the issues surrounding PPIs.
Increasing use of PPIs to infants under 1 year in NZ, not approved for use at this age, trials show no better than placebo (Otago university)- Not sure how this applies to Australia? (4)
Avoid long-term use, because of possible side effects. There may be a small increased risk of bone fractures, hip, wrist and spine, chest infections, kidney problems and decreased bone density
PPIs may cause nutrient deficiencies, namely magnesium, iron and vitamin B12
Recommended to assess need after 4 – 8 weeks, so why long term, for years?
Over one-third of people aged 65 years and older were dispensed a PPI in the last year (6)
PPI’s were the third most dispensed medicine in New Zealand, after paracetamol and Atorvastin (a statin drug for lowering cholesterol levels)
Changes are being made. In Australia on 1 May 2019 the pharmaceutical benefits scheme (PBS) changed criteria, both dose and duration. The previous year the PBAC agreed that high dose PPIs appear to be overprescribed in Australia, for excessively long periods of time, and particularly among older people.
It can be difficult to stop taking PPIs, so below I have a (very) basic description of how they work to illustrate why you may have trouble stopping their use.
Remember PPIs lower the stomach pH making it more alkaline.
Naturopathically, low stomach acid is a problem; we need well functioning gastric acid to digest and breakdown proteins, help the absorption of some vitamins and to combat any food or other bacteria entering the digestive tract that helps protect your gut from infection. Your body has a physiology to ensure homoeostasis so that requires your stomach acid to have a certain level of acidity. This acid level is controlled by the hormone gastrin.
The hormone roundabout; we have the hormone gastrin to facilitate the production of gastric acid. If your body senses a lowered level of gastric acid then your body produces more gastrin to bring down the pH of your stomach, increase acidity. Your next PPI increases the pH so more gastrin is produced to increase acidity??
It’s almost as if you’re trying to put your children’s toys away but they just go and bring out more, and more - still a heap of toys on the floor!
Do protein pump inhibitors (in the majority of cases) serve a useful solution to our digestive issues? Perhaps it’s about finding the lifestyle cause (more on stress later in this article)
To stop your children putting more toys on the floor, we have to teach them to put their toys away.
Your Digestion System and Effects of Stress
Those of you that have been to my clinic know that I always explain the stress response and the effect stress can have on your body. Imagine my joy while researching this article when I found research that shows stress affects your ability to digest food and uptake nutrients - so it is paramount to treat stress first before other gut nutritionals and even before major diet changes.
Research of over 6,000 people, all of whom had an upper endoscopy as part of this research, found that stress impacted reflux esophagitis (5).
They found that stress can:
Cause nonpropulsive activity of esophagus
Increase resting lower-esophageal sphincter pressure
Impaired sphincter relaxation, thus delaying acid clearance from esophagitis
Increases esophageal mucosal permeability
Let’s clarify and explain these research findings about how everyday stress may affect your digestive system.
When you eat, although you are upright your food just doesn’t drop down to your stomach via gravity, the muscles in the oesophagus contract in a wave like motion to move the food along through the oesophagus to reach your stomach. Stress impairs this process, reducing the propulsion of food through your oesophagus.
The sphincter, or valve, at the end of your oesophagus has to open and close in a precise manner to allow food to move easily and promptly into your stomach then close to prevent stomach acid entering your oesophagus and causing damage to the mucosa as, unlike the stomach, the oesophagus lining that has no protection to prevent damage by stomach acid.
The final point on the list above is about permeability of the lining of the oesophagus, permeability means gaps develop between the cells that form the lining of your oesophagus that should be a solid barrier, similar to bricks in a wall cemented together. Once this barrier loses it’s integrity food, chemicals or toxins can enter your body.
I hope you can see why, for many years, when people come to my clinic with digestive problems the first thing I talk about is stress, second is stress, then before a gut can be healed, detoxed etc…. we have to look at STRESS FIRST!
Great to see this backed up by scientific research.
Medicinal causes of Digestive Problems
At the beginning of this article I wrote about those of you preferring to find non-medicinal ways to treat symptoms, but what if a prescribed medicine causes other unrelated symptoms? In my research on PPIs there is a group of people who are prescribed PPIs due to the side effects of medication (2).
Patients with coronary artery disease were given omeprazole to control stomach problems caused by their medication. Of 706 patients in the study 431 took PPIs.
Researchers concluded that patients taking PPIs had a higher risk of heart failure and death, approximately 14.65% against 5.45%. So the inclusion of PPIs to treat side effects caused by the heart medication, gave a worse prognosis, a worrying situation.
This does open a whole new can of worms that I’ll not go into here except to say that a growing issue with the growth in medications in general may not be benefiting our health as we hope but leading to polypharmacy, additional medicines are needed to address symptoms caused by taking medication that has a range of side effects.
As I write this last sentence it sounds crazy!
Remember the effects of stress on your oesophagus that caused poor functioning and digestive issues (5). So if your stress impacts on the functioning of your oesophagus there are medicinal remedies for the symptoms. I found this information.
“Medical treatment of esophageal motility disorders involves the uses of agents that either reduce (anti-cholinergic agents, nitrates, calcium antagonists) or enhance (prokinetic agents) esophageal contractility.” (2)
Drugs have been known to have some sort of side effects on patients. Most of them are not often discussed in the health tabloids. While other drugs have side effects that are very nominal when compared to the benefits the patient derives from their usage, others have side effects that can impact the lives of their users forever.
Put together, drug-free movement amongst people coming to the clinic often only accepting necessary nutritionals to regain full health and wellness, acknowledging the impact of stress on the digestive system, especially chronic stress that can have a daily effect on the health and functionality of your digestive system is a move in the right direction.
This article has illustrated the problems, now being acknowledged by doctors that long-term use of PPIs is problematic. Now would be a good time to find the real cause of digestive issues, especially awareness of stress and other lifestyle factors and each of us to begin to take responsibility for our own health and wellness.
So just like the small children who need to learn to put away their toys. So must all of us, start to learn and to put into practice healthy lifestyle options?
Jean Jordan is a Kinesiologist and Naturopath in Christchurch, New Zealand and works with clients who have chronic pain and anxiety.
Visit PASC website to read more.
1. Heartburn Drugs Linked to Heart Failure, ‘Silent’ Kidney Damage by Michelle Llamas, Drugwatch.com March 1, 2017
2. Medical treatment of esophageal motility disorders. Dysphagia 1993;8920:125-34 Allescher HD, Ravich WJhttps://www.ncbi.nlm.nih.gov/pubmed/8467720
3. Gastro-info Dr Alan Fraser (MB,ChB,MD,FRACP) https://gastro-info.co.nz/gastro-information.aspx?pid=7
4. Off-label prescriptions of proton pump inhibitors to New Zealand infants is common: Dr Lianne Parkin, 4 May 2017, Otago University, https://www.otago.ac.nz/news/news/otago645236.html
5. The Association Between Reflux Esophagitis and Psychosocial Stress: Eun Mi Song, Hye-Kyung Jung, Ji Dig Dis Sci 2013 Feb; 58(2): 471-477 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3576549/
6. Stopping proton pump inhibitors in older people: Bpacnz: https://bpac.org.nz/2019/ppi.aspx