Have you ever taken antacids for indigestion?
And did the relief of these medications feel so good that now you can’t cope without them?
If yes, you’re not alone.
In Australia the drugs used for upper digestive discomfort called proton pump inhibitors (otherwise known as PPI’s) – account for over 15 million scripts annually. This does not include over the counter (OTC) sales. Why are so many of us suffering from reflux and upper gastro-intenstinal (GIT) discomfort and need such help? Has eating on the run been at the cost of holding anything down properly?
Heartburn or functional dyspepsia (indigestion) are common words most of us have dealt with or heard of before. Less commonly known gastro-oesophageal reflux disease (GORD) occurs when stomach acid leaks from the stomach and moves up into the oesophagus (food pipe). It is considered problematic when this occurs to you more than once or twice a week. Unfortunately for some people this discomfort is a daily and an every meal time experience.
Functional dyspepsia (FD) and gastroparesis (GP) are the two most common sensorimotor disorders of the upper GI tract, with shared symptoms of upper abdominal pain, postprandial fullness, early satiety and nausea.
Common symptoms of FD include:
Upper abdominal pain, postprandial fullness and pressure, early satiety, nausea, vomiting,
Common symptoms of GORD are:
Weight loss, heartburn, regurgitation, dysphagia (trouble swallowing). And less commonly – pain with swallowing, excessive salivation, nausea, chest pain (if with oesophageal injury from acid reflux), reflux oesophagitis, oesophageal strictures—the persistent narrowing of the esophagus caused by reflux- induced inflammation, Barrett’s oesophagus—metaplasia (changes of the epithelial cells from squamous to columnar epithelium) of the distal esophagus or lastly oesophageal adenocarcinoma—a rare form of cancer.
Knowing whether you have GORD, FD or GP is confusing as the symptoms and treatments are frequently the same.
While PPI’s can give temporary relief for all of the above they are however designed as a short-term medication, because they do not remedy the underlying issue.
These drugs types and names include:
Omeprazole – Prilosec/Prilose. Aspirin and Omeprazole – Yosprala. Ianosprazole – Prevacid. Dexlanasoprazole – Dexilent/Dexilent Solutab. Rabeprazole – Aciphex. Pantroprazole – Protonix. Esomeprazole – Nexium. Esomeprazole magnesium/Naxopren- Vimovo. Omeprazole/sodium bicarbonate – Zegerid.
The impact of taking these drugs are varied and multi-layered, including:
Small intestine bacterial overgrowth (SIBO)
Liver, kidney, pancreatic disease
Mood disorders, dementia in elderly
Mucosal gastric metaplasia/atrophy
Development of food-specific IgE intolerances
Reduced calcium uptake and increased risk to osteoporotic fractures >4 years of use
Iron and vitamin B12 reduced absorption
Increased risk of heart attack
Why heart attack? And how?
PPIs reduce endothelial nitric oxide synthase (ENOS) and inducible nitric oxide synthase (INOS). These are key enzymes in NO production. Because NO is vasoprotective – it decreases platelet activation – any reduction in this process increases peripheral vascular resistance and predisposes to inflammation and thrombosis. (Thrombosis occurs when a blood clot forms either in a vein or an artery even though you are not bleeding. The clot is known as a thrombus. Normally, blood clots only occur when you bleed).
We know how detrimental inflammation can be on all body systems, but particularly the cardiovascular and venous system. Lastly angiogenesis is dependant on NO. This is the formation of new blood vessels.
How to avoid this cascade of illness?
It is important to note that stress is a common and potent cause and consequence of upper GI digestive disorders. Also the health of the upper digestive tract determines the health and environment of the rest of the digestive tract. Commonly patients with upper GI complaints have SIBO and bowel dysbiosis too. Treating these complaints will go a long way in helping to resolve or reduce your antacid dependence.
Managing upper GI medications
Despite misconception to the contrary, hyperacidity is seldom the cause of upper GI conditions, and yet medical management targets acid production. Stopping antacid therapy (PPI and H2 receptor antagonist) is known to cause withdrawal symptoms and rebound hyperacidity in up to 40% of patients. Rebound hyperacidity that can develop after PPI withdrawal may actually cause an acid-related upper GI disorder, when there was no hyperacidity issue in the first instance.
Factors that contribute to Upper GI complaints in the first place include:
- Hiatus hernia, due to mechanical and motility problems.
- Obesity – creating pressure under the diaphragm
- Common dietary irritants – Fatty and fried foods, chocolate, garlic and onions, caffeinated drinks, acidic foods such as citrus fruits and tomatoes, spicy foods, mint flavourings
- Gluten sensitivity
- Stress or mood disorders
- Helicobacter pylori infection (we can test for this)
- Poor eating habits – excessive carbohydrates, eating too large meals, eating directly before bedtime
- Use of alcohol or cigarettes
- Poor posture (slouching)
- Congenital weakness of lower oesophageal sphincter
- Hypercalcaemia, which can increase gastrin production
- Gastroparesis (delayed gastric emptying of a solid food meal with no obstruction)
- Multifactorial aetiology; including diabetes, prior surgery, ischaemia, connective tissue disorders, radiation, inflammation, medications and vaccinations. Gastric outlet obstruction or pyloric stenosis
- The use of some medications may predispose to reflux, such as calcium channel blockers, teophylline (Bronchodilators), nitrates (used in angina management) and antihistamines.
What can you do to at home to support your upper GIT health?
Avoid foods that promote reflux, induce delayed gastric emptying, oesophageal sphincter relaxation or direct irritant effects, including citrus fruits, chocolate, caffeinated drinks or alcohol, fatty and fried foods, garlic and onions (especially raw), mint flavourings, spicy foods, tomato based foods, carbonated (fizzy drinks) – especially if caffeinated.
Low carbohydrate diets are effective for managing GORD, to reduce excessive small intestinal bacterial fermentation and excessive gas causing upward pressure on stomach contents. Also visceral fat mass exerts mechanical pressure on the stomach so losing weight around the mid-riff especially can help. Carbohydrate restriction is suitable regardless of body composition to manage oesophageal acidity, whether weight loss is the goal or not.
Reduce meal size to minimise fullness and distension. Increase meal frequency to achieve caloric and nutritional requirements.
Reduce fat and fibre, as these may slow gastric transit time. Utilise liquid meals to increase gastric transit time and boost nutrition.
Avoid or minimise alcohol and carbonated drinks to prevent bloating and distension. Avoid tight garments in those with abdominal obesity.
Elevate the head of the bed. Avoid eating 2-3 hours before bedtime.
Avoid smoking, as this reduces lower oesophageal sphincter competence.
Alginic acid (Gaviscon): May coat the mucosa as well as reduce acidity and decrease reflux.
Prokinetics: Strengthen the lower oesphageal sphincter (LES) and speed up gastric emptying.
Sucralfate: Used as an adjunct to help to heal and prevent oesophageal damage.
Nutritional support to help:
Treatment needs vary greatly between individuals. Broadly speaking digestive enzymes – vitamin B12 and B complex formulas, vitamin D, Magnesium, Zinc, Wholefoods/Superfoods powders for quick uptake of key nutrients, and mibrobiota support via probiotics can all help. I stock a wonderful new chewable product called “PeptEase” which is designed to help you wean off antacids if that is your choice. It is a Practitioner Only product available with professional consultation. My clients who have begun PeptEase love it!
It is clear that any of us can be likely to need reflux medication relief at some stage of life. We must understand how long that treatment is best taken for and if there are any potential side effects that could complicate our original symptoms. For a better understanding of your own upper GIT needs, book in for a consult. It is Your Health, Your Choice, so if continuing to stay on PPIs is preferred, we work with optimising that script benefits and reducing any impact on your overall wellbeing.