Are PPIs Safe? (What I tell my patients as a GI doctor) 

I have GERD, and I seriously wouldn't want to live if I didn't have my PPI medication. It's not just discomfort, it's straight up painful, impossible to sleep, and even when I sleep, it's acid in my throat, nose and ears when I wake up. almost any possible side effect is worth it. I still have to avoid chocolate, fruit juice, alcohol and filling up my stomach too much, to avoid any symptoms though. I remember crying tears of happiness after my first night of sleep after taking omeprazole. I didn't know you could sleep without pain.

Something that seems to happen a lot is that patients would get discharged from a hospital and they'll continue a PPI that was started inpatient for stress ulcer prophylaxis. Then the patient just keeps getting that refilled for years, not knowing that it was started for a very specific reason.

My favorite PPI patients are the ones that were put on a short term PPI 5-10 years ago during an inpatient stay in a hospital and it just kept getting refilled as a maintenance med for years until I (pharmacist) ask them why they are taking it during a CMR and they say they have absolutely no idea, it’s just been in their pill box every month for the last decade. This is way more common than it should be.

Thank you for this! I really appreciate your PSAs. 😊 I take 20 mg of Omeprazole twice a day, and have been for six years. Even when I went down to once a day, my symptoms came back. My symptoms don’t really bothers me because I have silent reflux, but I have chronic erosive esophagitis, and it’s really important to control the reflex because of complications from that are far worse than potential risks from long-term PPI use. I just wish people who don’t know my medical history would stop criticizing me for taking it, or my doctors for prescribing it. The way I see it is, based on my tissue biopsies in my 30s, uncontrolled stomach acid going into my esophagus has a much greater likelihood of causing serious complications, including cancer and death. Whereas potential complications, based on retrospective studies, have a much lower probability of causing potential conditions that may develop even without taking a long-term PPIs. I am more than happy to take my chances with the medication.

As a pharmacist, we see a lot of prescriptions for PPIs. It’s usually either to treat excess acid or reflux conditions or it’s used with other medications that can alter acid behaviour, so it’s more like a prevention, normally long term use. PPIs interact with other medications too so make sure the doctor or the pharmacist knows the list of drugs you’re already taking.

I have been on pantropazole for 8 years now. I tried other options for my constant stomach situations and my Gi had me come in for an upper and lower and now I'm on the best medicine I ever had. I can eat anything and not have heartburn. My stomach doesn't burn and it doesn't feel raw. But I love that I am not eating antacids everyday like candy.

I was prescribed Omeprozole first and when that didn’t work, Dexilant. That didn’t work either. I was given the usual advice of avoiding spicy food(even plain oatmeal gave me heartburn) and was asked to eat 2-3 hours before bedtime. Nothing worked. Out of the blue, I started circadian rhythm IF and finished my dinner by 6 pm. That made night and day difference. I only have heartburn on days I eat later. Stress also plays a HUGE role in GERD. I’m sure PPIs are necessary for some people, but we can’t ignore the long term effects especially given what they are intended to do in the gut.

I have been on omeprazole long term. It’s been wonderfully effective in preventing GERD, which was persistent and very painful.

It is also important to know how PPIs affect you together with other medication. Omepratzole for example can be a serious danger when taken together with certain antidepressants. Talk to your doctor and pharmacist about what medication you are already taking, especially when getting a new one for the first time!

Gold star for saying PPI that many times without giving up🎉 they are a godsend for those of us who breathe fire 🔥

I've been taking a ppi...probably 20 yrs now, but as a young child I couldn't drink orange juice and Sunny D was acid in a bottle. No Nutragrain fruit filled cereal bars, there were so many foods that made my stomach hurt and would give me reflux and acid diarrhea. Any kind of juice, lots of foods, and I probably should have been on a fodmaps diet but that would have meant admitting I really had a problem, which Mom was never gonna do. I felt so hungry all the time because my stomach was always growling there were times when I'd wake up with reflux and calcium carbonate antacids made things worse and my vocal cords would get drenched in stomach acid and I'd have to go downstairs and sip some milk to cool things off. I was scolded for being a "picky eater" and saying "but it makes my tummy hurt!" Or "I don't wanna burp acid," was apparently an excuse to cover my bad attitude. I was nearly an adult before I discovered what it was like to NOT have stomach pain and growling 24/7. Holy crap do I feel better! I do have B12 & D3 deficiency and use sublingual B12 drops daily and D3 pills, but I'm also on a low meat diet for p-ANCA vasculitis and ckd (though I'm finally in remission), and spend almost all of my time indoors. The double scope about 12 yrs ago still showed esophageal irritation that I couldn't feel and I had a few polyps removed. I'm overdue for my next scope but it takes 6 mos to get in to see my gi and I have so much else going on that I lose track.

Very good PSA about a common question,.

All my maternal aunts and uncles have Barrett’s esophagus and my grandfather died of esophageal cancer. I “just” have GERD and I hope it stays that way. I’ll be on PPIs forever. Apparently my family makes terrible sphincters…

This is super helpful, thanks Doc! I was started on my first ever PPI earlier this year for GERD which was supposed to be temporary. It worked extremely well though because I couldn't sleep without it (I would periodically wake up and feel nausea and occasionally need to vomit.) It stopped the night after the morning I took my first Panto. A couple months later I tried to go off it but was miserable and have been taking it once a day ever since. I knew there were risks of "long term use" but I didn't know what "long term use" actually meant. I thought it was more than 3 months. Thank goodness it means years. I still want to get of the Panto though. :/

Great review and resource - thanks doc 🤙

Thanks. I was on PPIs for decades (I remember my GI doc was so excited when they came out!) and the benefits clearly outweighed the risks. I have had a gastrectomy now and my surgeon monitors for a lot of things, including osteoporosis and kidney disease.

Yup. Congenital hiatal hernia. Been on PPIs since 2004ish, and will until I die or can afford risky esophagus surgery.

PPIs often get prescribed for heartburn without screening patients for stomach acid levels. It is important to know that often heartburn can be caused by not enough stomach acid. Not enough stomach can cause bloating and infections of the pyloric spyncter, so whatever acid there is can leak out and cause heartburn. I treated myself with a temporary course of betain hcl tablets and after 15 years of PPIs I'm now medication-free! My GP is not interested!

Thank you ❤❤

There's a lot of nuances to medications in general, which is why it's important to consult your doctors or pharmacists regarding them. A medication that you may be taking for a certain condition may be completely different from why someone else might be taking them for. And depending on what conditions you're treating and what other medications you're taking alongside it can drastically change what to be on the look out for in terms of side effects and effectiveness. Something that I commonly see in pharmacies are people who come in with questions or misconceptions about their own medications based on what other people on the same medication has told them. And unfortunately, also instances of people who had discontinued their prescription medications or started on an over the counter medication because of what they heard, which later devolved into problems that could have been prevented in the first place. This is why accessible healthcare is important and why you should always advocate for it.

Thx for info

Went to med school in the early 90s,we had a limited time recommended for use. Make sure you get b12 checked if on chronically and the kidney doctors really want your kidneys checked.

I was prescribed a PPI over a decade ago. I was having bouts of being unable to swallow [yes, I had swallowing tests]. I asked my Dr the same thing, and he gave the same response you did. If I miss one pill, I get bad heartburn. More than one and the swallowing issue rears its ugly head. I am tested for the possible side effects and do not have them. So glad to be able to swallow!

As somebody who has been on high dose esomeprazole for around 24 months (gastritis, oesophagitis, and oesophagitis along with daily coffee ground vomitus and weekly frank haematemesis) this video is really interesting. I've had far too many EGDs in the hospital I work at!

Protonix really helped me with heartburn caused by achalasia. Before my I was taking protonix twice a day.

That's useful information. I've been taking a PPI for several decades and was unaware of these rare effects. Of course, I should have done my own research and not rely on some unknown bod on the Internet for my medical advice.

Thank you for the short CEU. The question I have is How to wean patients off of PPI and helping them through rebound affects because they’ve been on it for so long?

Oh, I thought PPIs was Payment Protection Insurance.

My dad had acid reflux for 50 years, was on PPIs for the last 21 years of his life before dying of esophageal cancer

I think this sounds great except when you go on a mediation it's rare that a doctor says "there are risk factors for a few diseases long term associated with this medication. Let's follow up with blood work and dexa scans at these intervals" - they wait for you to come back and complain to them... AFTER you already have terrible side effects. Meanwhile, I personally would be thinking that my side effect symptoms were just in my head. As happened recently with my severe leg pain while on a med for lowering cholesterol.

I was on omeprazole for a number of years. But I grew concerned about it. I weaned off of it and transitioned to famotidine. I had so much pain in the 3 to 4 weeks I was weaning off of the omeprazole. Never going back on a PPI again.

So I’ve been on opmerazole for about 8 years I do have barrett’s should I be looking to get away from it? Good information thanks

According to Tim Spector and the ZOE team PPIs very negatively affect the gut microbiom - I don't know what study is the exact source, but I generally trust Tim Spector, so I would take this into account when deciding between treatment options for myself. The price I pay for harming my microbiom with antibiotics (they were necessary - for the record) made me rather cautious in this regard.

I kept trying to wean off my daily omeprazole for GERD, and it kept working for a while, and then not, and I had to go back on it. I'm now on 20 mg omeprazole twice daily. I asked my primary about this since I had heard long-term omeprazole use isn't good for you, and she pointed out what you said that the complications can be monitored for, and also that under-controlled GERD has greater risks than long-term monitored PPI use. That put me enough at ease about my 40 mg a day of omeprazole that I see no need to try to wean myself off it again unless complications do start to arise.

As a long-term Prilosec patient (GERD), and as a trained research scientist in a non-medical field, I have been following this with interest. A couple of thoughts: (1) The adverse effects may simply tell us that people who take PPIs are getting more medical care and so are more likely to have the other conditions detected. That is, maybe Prilosec doesn't cause dementia, but if you take Prilosec, you see a doctor twice a year and your dementia will not go unnoticed -- you're not one of the gang who go five years without seeing a doctor. (2) I saw a large study in Denmark of (I think) 18,000 patients that did not find an association between PPIs and dementia. That's substantial statistical power. I'll see if I can find the reference.

I sincerely hope they are safe because you prescribed me some lol

I was prescribed 100mg omeprazole (over the course of a day) for GI issues - at every follow up, I'd ask if I should continue taking it, and they always said yes. After a few months, I decided to cut back on them. Lots of stomach pain, burning, and esophageal pain in the morning when waking up, etc. I cut down to 20mg a day and continued that for 2 years, and then decided that because of the long term effects, and my young age (20 odd years old) I certainly didn't want to be on them for the rest of my life, so I slowly worked down from 20 to 0, which was much, much harder than 100 to 20, especially after such a long time. But now that I'm done and off them completely, I feel really good about my health! Not only my comfort that I'm not on a short term medication for a long period of time, but my base level of stomach acid has corrected a bit as well, and I no longer get early morning or late night stomach discomfort when my medication isn't fresh in my system.

what are your thoughts on SIBO? How would you treat?

My oncologist/surgeon put me on PPI due to barrettes esophagus and esophageal cancer. He said the acid reflux would scar my esophagus and potentially give an opportunity for cancer to recur. I don’t find the medication reduces the reflux much. Diet, restricting coffee and avoiding late night eating makes a difference.

I was on omeprazole for a while, and it helped with the heartburn while awake, but changed the consistency of my stomach acid and made the issues with waking up with acid in my throat much worse.

I'm going to have to keep an eye on this for me, I take Omeprazole for GERD and want to avoid these negatives as much as possible, but also I'd honestly prefer to live a few years less, than live the rest of my life with crippling GERD symptoms

I've been taking oméprazole for about a year. It started with me waking up with a sore throat every morning. I tried making my room more humide, and I know that I don't sleep with my mouth open, so I was at a loss - until I started feeling an acidic taste in my throat at night and started having some mild nausea that I wasn't having before. My doctor put me on oméprazole and sent me to a clinic for them to look down my throat all the way to my stomach to try and see if there was some issue, but they didn't find anything. And since the acid reflux kept coming back if I ever forgot to take the oméprazole, and my doctor was fine with prescribing me more when I came to see her, I've been taking it ever since. The issue I have is that, since I don't know what causes it and taking it mostly dissipates the symptomes, I don't exactly know if I could technically stop taking it? But I still have acid reflux more often than I used to - eating candy can trigger it, for instance - so I assume it must be keeping more at bay... Hhh. I wish I knew why it did that

So, are PPI's fine to take with fluvoxamine, an SSRI, give that fluvoxamin inhibits the same enzyme that esomeprazole is absorbed through pls?

My GI doctor has me on a PPI because I'm a person that overproduces stomach acid to the point that it rips holes in my esophagus and stomach and I get GI bleeds. They said I likely will be on them for life basically and I'm not happy about that cuz I'm worried if I take them long term that I will just make more and more stomach acid. I can easily make 3+ liters of stomach acid when I eat nothing in a day or more. I wish there was a better treatment and there was a way to get off of them.

Can dementia be reliably caught with monitoring, and are there actually effective treatments if it is found early?

My 7-year-old is on a long-term PPI for his EoE. Are there any tests we should be doing to monitor for these side effects?

I recently stopped taking PPIs after around 6 years of use, I am concerned I may have done some damage but the doctor said I should take them because I have a history of repeat hemorrhaging ulcers. I have not had an ulcer in years.

I just have the impression that medical studies have so many confounders it is sometimes impossible to get a clear answer - but my understanding skills of studies is limited

Was on Dexlansoprazole (Dexilant) for 15 years for GERD. Managed to get it down to 1 pill a week. Then the patent expired and a generic was released and now it's too expensive to afford because both the generic and the name brand are not cheap on my insurance, and Dexilant canceled their discount card. So now I'm taking Lansaprazole 3 or 4 times a week because it doesn't work as well for me. Also been taking magnesium supplements for almost as long to counteract the meds robbing my body of it. Would have been nice if a normal course of PPIs stopped my GERD instead of having to be on them forever.

My dad’s been taking nexium for like 20 years for reflux and has never had a problem

Curious about something. I have heard conflicting views on if PPIs are safe for pregnancy. Many women have very severe heartburn for months and months and ypu'd think it would be something that would be a priority ffor doctors to know to treat that very common side effect. What are your thoughts?

Not satisfied, please call your PA for a consult, then try again

Hey Ben, what do You think about giving PPIs to every patient prescribed NSAIDs or steroids, even if they have no risk factors and tolerated said drugs well before? A lot of doctors I know do it as a routine.

I feel like this is too simplistic a conclusion to reach. I have stomach pain because I had cancer and they removed part of my intestines. I also have a B12 deficiency, but that’s not from omeprazole, it’s from my other health conditions.

I wish someone would tell my insurance company. They won’t cover them for longer than three months a year. My GERD is year round! Ugh.

I’ve always had the weird wonder, what if you somehow take them too strong end up not having enough stomach acid to actually digest food? Sounds like an overdose I guess but somehow it’s always made me wonder

Ok but real talk the H. Pylori treatment is no joke and I’m not looking forward to doing it again 💀

What if I take OTC PPIs long-term and don't have a doctor monitoring the risks? How long can I do this before I need to see somebody about it?

I wonder how much potential over-prescription is cultural resignation on the futility of treatment recommendation especially with regard to diet change and patient behavior with prescription insistence. Not that the recommendation of diet change never happens but that it's handwaved, ignored or excused by patients so often that a rut has formed in the treatment road that is easy to go into -- pepperoni pizza and a pill vs esophageal cancer.

Hypothetical question: if a patient has low b12 and enlarged red blood cells, but the intrinsic factor antibody test comes back negative, what would be the next step in terms of tests or treatment? asking for a friend 🙂

Hm. So someone with high risk for osteoporosis might need to think twice about taking PPIs for more than a short time, and not repeatedly, I would assume.

Pantoprazole ftw

If you’re taking PPIs for heartburn, then it’s always for long term use.

Do you guys do any research on your stomach not having the right amount of acid and acid reflux is actually just food fermenting in your stomach? That's the conclusion I came to when I was diagnosed with acid reflux. Talking to others of the age 40+, it's very common. Been pushing then to eat tart delicious apples as a solution, it seems to work and you don't even have to eat 'em every day, just a couple times a year or so.

PPIs have a place in therapy but for most people are used too long. Patients try to stop the medication & then experience rebound acid reflux & think they’ll never be able to stop so they don’t. It can take months to taper off the medication. Saying, I’ll prescribe it until the dexa scan comes back bad, or the b-12 comes back low is ridiculous. Are you, as the gi doc, going to monitor the patient & ensure they even get a dexa scan? Because their pcp is waiting for evidence of osteoporosis or osteopenia before ordering the scan in patients who perhaps don’t present as frail white women of diminutive stature. I understand the argument against the studies, but there are many other good recommendations we could ignore because the evidence was collected from retrospective data - doesn’t mean we should.

And in actual RCT data the incidence of these side effets are almost 0

Yeah, there's no monitoring in Hong Kong. There's no way I was going to do that long term. I must find the cause. Spoiler alert, a bunch of tests later, no cause has been found.

They're not meant for long term use

Everyone should check in to the dangers of these. There are possible dangers that can happen after taking them for even three or four years. I personally know of them. They are not suppose to be taken long term.