Warning: This is a man bites dog story. In other words, it contradicts conventional wisdom.
Physicians have long recognized that popular pain relievers like aspirin, ibuprofen and naproxen can harm the digestive tract. These nonsteroidal anti-inflammatory drugs (NSAIDs) are a mainstay of arthritis treatment, but they often cause heartburn and other digestive distress.
To counteract the stomach irritation they cause, many doctors prescribe proton pump inhibitors (PPIs) along with NSAIDs. Drugs like esomeprazole (Nexium), lansoprazole (Prevacid) and omeprazole (Prilosec) help prevent stomach ulcers.
PPIs + Pain Relievers = Unexpected Damage
A recent review suggests, however, that this combination might be causing havoc in the small intestine (Mayo Clinic Proceedings, Dec. 2014). NSAIDs cause damage not only to the stomach. Such drugs can also injure the delicate lining of the small intestine. As little as two weeks of NSAID treatment can cause lesions in the small intestine of more than half the patients (Clinical Gastroenterology and Hepatology, Feb. 2005).
Surprisingly, when acid-suppressing drugs are added to NSAIDs, the small intestine suffers even more damage. One study showed over 80 percent of patients on such combination therapy end up with lesions after only two weeks (BMC Gastroenterology, May 14, 2013).
Upsetting the Bugs in Our Belly
Why would PPIs make the digestive tract below the stomach more vulnerable to damage? The answer appears to be in the bacteria living in the small intestine. Acid-suppressing drugs change the ecology of the gut.
The bugs in our belly are supposed to live in harmony. PPIs apparently disturb the balance of different types of bacteria, reducing the protection they normally provide to the intestinal lining. This worsens the damage caused by pain relievers.
Scientists believe that stomach acid normally kills off swallowed bacteria. By reducing acid levels in the stomach, the digestive tract is exposed to germs that would not normally survive. Several serious GI infections have been associated with PPI therapy, including the hard-to-treat germ C. diff (Expert Review of Clinical Pharmacology, Jul., 2013).
Another complication of bacterial overgrowth in the intestines is pneumonia. Regular use of PPIs has been linked to lung infections, especially in older people (Drugs & Aging, Jan. 2015).
Do PPIs Increase the Risk for Cancer?
This is a highly controversial question. Most gastroenterologists believe that acid-suppressing drugs reduce the risk of cancer, particularly in the esophagus. It is standard medical practice to prescribe a PPI to anyone with abnormal cellular growth such as Barrett’s esophagus. The belief is that such drugs will prevent those abnormal cells from developing into cancerous tissue.
A Danish study found the opposite, however. Long term use of potent acid-suppressing drugs was linked to an increased risk of adenocarcinoma of the esophagus and higher grade dysplasia (abnormal cellular growth). You can read more about this highly controversial study and the potential reasons for this unexpected outcome at this link: Do Acid Suppressing Drugs Protect Against Cancer or Increase the Risk?
FDA Says PPIs Are Safe for OTC Use
Despite these complications, the FDA considers proton pump inhibitors safe enough for over-the-counter use. Most pharmacies now prominently display Nexium 24HR, Prevacid24HR and Prilosec OTC.
The warning on such products states that they should not be used for more than two weeks and no more often than every four months. The FDA may believe that this will protect consumers from adverse effects such as fractures or infections, but many people disregard such instructions.
People who would like to know how to treat symptoms of heartburn without relying on powerful acid-suppressing drugs will be interested in our Guide to Digestive Disorders. It discusses the challenges people often face getting off PPIs and provides some tips about how to manage this daunting task.
It may take some time before health professionals recognize the danger of recommending PPIs together with NSAIDs. Until then, patients will need to be vigilant and do their own homework. Our Guide may help you get started.
