On the surface, Sean "P. Diddy" Combs, Larry the Cable Guy, Rosie O'Donnell, and John Elway have little in common. Yet, these popular figures, successful in very different fields, each had to take time off for the same reason: acid reflux. Just this month, in fact, star Baltimore Orioles right-fielder David Markakis was kept out of action for the second time in his career for complications relating to acid reflux. While our favorite Cable Guy for years has been telling us to "take the purple pill," recent clinical studies tell a much different story about what the pill is doing.
Almost one in three Americans experience symptoms relating to acid reflux monthly, and the majority of those suffer from Gastro Esophageal Reflux Disease (GERD). [1] Left untreated or even treated incorrectly, this progressive and chronic condition can result in a very low quality of life and in some cases esophageal cancer. The most common symptom, heartburn, is a result of acidic stomach contents contacting the lining of the esophagus resulting in pain and discomfort. For most people, intermittent heartburn means taking a few antacids and waiting for the pain to subside. For those with frequent symptoms, however, doctors often prescribe Proton Pump Inhibitors (PPIs), a drug class that includes Nexium, Prilosec and Prevacid, to name a few popular brands. Though the warnings on the over-the-counter label and in all promotional ads state these pills should be used for a maximum of 14 days during any year, many patients continue on their prescribed medication for months or years without understanding or learning the risks.
These PPI pills reduce or eliminate the symptoms of GERD by blocking the stomach's production of acid, which when reflux into the esophagus causes heartburn. While these pills provide for short-term and temporary relief, blocking the body's production of acid on a daily basis has its downside. The FDA warns that the long-term use of PPIs is associated with decreased calcium absorption, leading to bone fractures, decreased absorption of magnesium leading to hypomagnesaemia and heart arrhythmias, increased incidence of pneumonia, and increased incidence of Clostridium difficile infections.
For many sufferers, PPIs certainly have been a blessing -- but at what cost? According to a study by Dr. Blair Jobe at the University of Pittsburg, PPI-treated GERD patients, who have mild or absent symptoms while on the medication, were 60 percent more likely to have Barrett's esophagus, a precancerous condition, than those with more severe symptoms while on the medication. [2] Disappointedly, a good response to the medication does not eliminate the risk of cancer. In another ongoing long-term study conducted in Europe, researchers determined that today's treatment model, which is predominantly focused on drug therapy, does not stop the progression of the disease. [3] More importantly, of all the risk factors studied, which included diet, obesity, smoking, alcohol use and family history, the one factor with the highest odds ratio associated with progression from mild to severe disease and leading to Barrett's Esophagus was daily PPI use. So why are reflux disease patients treated with today's routine clinical care standard most at risk for pre-cancerous conditions or esophageal cancer?
In addition to the potential for costly adverse events, these drugs also represent a staggering financial burden on the U.S. health care system when inappropriately prescribed. Dr. Heidelbaugh of the University of Michigan found that 36 percent of PPI prescriptions were for "no documented appropriate use." [4] More importantly, 49 percent of all PPI users in this study never had follow up examinations to determine improvement or if continued PPI therapy was even necessary. The annual cost of PPIs in the U.S. is $11 billion, and based on the above percentages, the inappropriate use of PPIs results in $4 billion to $5.4 billion of excess costs each year in the United States alone.
The standard approach to combatting acid reflux has failed -- no temporary or quick-fix solution is the answer to the long-term problem of acid reflux and GERD. It is time for those suffering with GERD to take a hard look at their daily eating and drinking habits, learn about this painful and chronic condition, and take an active role in managing their disease. Americans are eating later, consuming more alcohol and eating larger portions while thinking a few pills are an acceptable substitute for personal responsibility. Clinical research has shown that the only true remedy for GERD is a healthy and conscious lifestyle, including the appropriate amounts of healthy foods, limited consumption of alcohol, regular physical activity, and appropriate treatment when necessary. While a few pills might have helped Elway in a pinch before a big game, for the rest of us nothing will supplant a lifestyle change -- eat earlier, eat less, eat smarter, drink less alcohol, exercise more and when your body tells you something is wrong, see the right physician to find out what is really going on with your body. Masking our problems with a pill is creating more problems for many.
References:
[1] Locke GR 3rd, Talley NJ, Fett SL, et al. Prevalence and clinical spectrum of gastroesophageal reflux: a population-based study in Olmsted County, Minnesota. Gastroenterology 1997;112:1448-1456.
[2] Nason KS, Wichienkuer PP, Awais O, et al. Gastroesophageal reflux disease symptom severity, proton pump inhibitor use, and esophageal carcinogenesis. Arch Surg. 2011;146:851-858.
[3] Malfertheiner P, Nocon M, Vieth M, etal. Evolution of gastro-esophageal reflux disease over 5 years under routine medical care - the ProGERD study. Aliment Pharmacol Ther 2012;35:154-164.
[4] Heidelbaugh JJ, Goldberg KL, and Inadomi JM. Magnitude and economic effect of overuse of antisecretory therapy in the ambulatory care setting. Am J Manag Care 2010;16:e228-e234.
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