Following on from last week (Ep 62 - Acid Reflux) this week is all about PPIs and how they affect the rest of your health.

• How does a proton pump inhibitor work to reduce stomach acid?
• Impact on your gut microbiome
• Nutrients impacted by reduced stomach acid - iron, magnesium, B12, calcium
• Are H2 blockers better than PPIs?
• How to tackle the acid rebound when stopping PPIs

Work with me

• 3 month Gut Reset - https://www.goodnessme-nutrition.com/consultations/
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The information in this podcast is not medical advice and is not designed to treat, diagnose or provide personalised health advice. This podcast content is information only and any changes you make are at the user's own risk. Please consult with your doctor or healthcare provider before implementing any new treatment.

Should you take a proton pump

inhibitor for your acid reflux?

2

In this episode of the Inside Knowledge,

I'm going to be sharing my thoughts

3

on the benefits and implications of

taking acid suppressing medication,

4

even if you're worried about small

intestine bacterial overgrowth.

5

If you've listened to episode 62 all

about acid reflux, you'll know it is

6

so important to stop the acid burning

and of course to avoid the pain and

7

discomfort, but also the long term

consequences of burning your esophagus.

8

So this episode is going to cover

the medication for acid reflux

9

which reduces your stomach acid

and can also affect Welcome

10

to episode 63 of the Inside

Knowledge, I'm Anna Mapson.

11

Last week I talked quite a bit about,

um, what you can do for acid reflux

12

that doesn't involve medication,

things around changing your eating

13

patterns, some specific foods that

may affect acid production, and

14

the way that your lower esophageal

sphincter can open to let the acid out.

15

So take a look at those if you

haven't already, because that

16

is the first place to start.

17

But this week I'm going to be talking

about the things that we can take

18

from the doctor in If you have high

levels of stomach acid, reflux, and

19

ongoing heartburn that is not resolved

by those kind of lifestyle changes.

20

The most common medication

that you may be prescribed is

21

called a proton pump inhibitor.

22

These are brand names like

Omeprazole, Esomeprazole, or

23

Pantoprazole, or Lantoprazole.

24

They all end in O Azole, basically.

25

Um, but there are other types of

medication as well that work in a

26

slightly different way histamine

blockers, and these are sometimes

27

called rinitidine or famotidine.

28

These are Working in a

slightly different way.

29

So I'm going to get into the

mechanisms of those in a minute.

30

I'm also going to talk about the

implications of taking these medication.

31

So what happens when we stop our

stomach acid because we do need it.

32

In order to explain how the medications

work and the implications of using them

33

longer term, you might need to understand

a little bit more about how acid in

34

our stomach is actually triggered.

35

So, sometimes it's a conditioned

reflex that we will anticipate food.

36

You know that you can get that sort

of Pavlovian response to a delicious

37

smell and maybe your saliva starts

going, you start anticipating the

38

food, maybe your stomach starts

rumbling when you're a bit hungry.

39

So, That cephalic response,

that's like our brain stage of

40

digestion, that can also trigger

acid production in the stomach, but

41

we also get an increase in stomach

acid when we actually start to eat.

42

So food comes into and stimulates

the stomach to release acid.

43

There are cells lining your

stomach called the parietal cells

44

and these have the thing in them

that's called the proton pump.

45

The pump, what it's doing is it's

exchanging potassium ions, then we're

46

getting down to like really chemical

structures of your food and your

47

biology, but the potassium is being

exchanged for hydrogen, so it's pumping

48

in potassium and pumping out hydrogen.

49

When hydrogen is reaching other

cells, then acid is produced by those.

50

So this is why the proton pump

inhibitor, which is stopping this

51

proton pump from doing its work, is

going to stop the acid production

52

because it stops hydrogen production.

53

Now, part of this as well, at the

same time, your vagus nerve, which

54

can be stimulated by your brain and

your thoughts, but also by food,

55

starting the mechanical process of

digestion, histamine is also secreted

56

from other cells within the lining of

your stomach, which also stimulate the

57

parietal cells to release hydrogen.

58

And in that way, we've got these two

methods for creating hydrogen, which

59

then triggers the production of acid.

60

So we can either block the histamine

production, or we can block the proton

61

pumps from doing their work, and that will

stop acid being produced in your stomach.

62

Because the lining of your stomach

is being renewed every three days.

63

So there's constant turnover.

64

Some of the cells are being

renewed every second of the day

65

and every second of the night.

66

So over the course of three days,

the entire lining of your digestive

67

tract will have renewed itself.

68

When we take a proton pump

inhibitor, it is extremely effective.

69

It can stop the acid production by

somewhere like 75, 80, 90 percent.

70

It completely blocks the

production of that cell.

71

But, because we've got this constant

turnover, there will always be new cells

72

that are starting to grow and starting

to produce acid, which is why you need to

73

take a proton pump inhibitor every day.

74

Some people who find they take it and

are still getting symptoms will find

75

that splitting their dose and taking

some in the morning and some in the

76

evening is actually more effective.

77

Because you might have a very fast

turnover of cells and you may find

78

that a single dose doesn't last enough.

79

It's best to take your proton pump

inhibitor in the morning rather

80

than taking it at night before

bed because you've got the most

81

action during the daytime when

you're actually going to be eating.

82

During that kind of renewal

process, every 24 hours, 20 percent

83

of the pumps will be renewed.

84

Within stopping taking your proton pump

inhibitor, you'll be fully back to all the

85

acid production within two to three days.

86

The cells will start to do their

work again and you will start to

87

get acid production pretty quickly.

88

Something that is really common when

people stop taking their PPI, they can

89

experience something called acid rebound.

90

You can think about it like your

body is still sending the messages

91

to these parietal cells in the lining

of your stomach to produce acid.

92

Imagine like a water dam that is pushing

back the water and holding it back so

93

that no water can flow down the river.

94

If you suddenly take that dam away, and

you take the brakes away, then you can get

95

a flood of water coming through, and that

is the same kind of thing with your acid.

96

Your body does not understand why no

acid is being produced, so it sends

97

more and more messages to the cells

saying, make acid, make more acid.

98

And then, if we take off the brakes,

we suddenly release the water.

99

this dam and they're going crazy

creating a lot of acid which can

100

then lead to much worse symptoms than

maybe you had in the first place.

101

You might stop taking the proton

pump inhibitor and actually think I

102

definitely need it there is no way I

can stop because it's so much worse

103

and this is down to the rebound effect.

104

Some people who are taking a PPI

will just need to be on them for the

105

rest of their lives or for as long as

they have another condition going on.

106

Some examples of this is people

who've got Barrett's esophagus.

107

This is where the esophageal lining

is damaged due to acid burning it and

108

if it continues to be burnt, may lead

to cancerous changes in the cells.

109

So if you've got Barrett's esophagus,

unfortunately you need to stay on

110

a PPI for the rest of your life.

111

Other people who may need to take a

PPI longer term are people who rely

112

on pain medication such as ibuprofen.

113

These non steroidal anti inflammatory

drugs, will also cause damage

114

to the lining of your stomach.

115

And so we need to protect it by

stopping the acid production.

116

So if you're someone who is going

to be Constantly in need of pain

117

relief, we need to protect your

stomach and stop the acid production.

118

If you've got an ulcer inside your

stomach, then you also need to stop

119

the acid production for a short time

until your stomach lining can heal.

120

If you've got esophagitis, that would

be a condition you need to speak

121

to your doctor about, but normally

people stay on a PPI because of that.

122

So there are other instances.

123

Do not stop your PPI unless you've had a

conversation with your doctor or unless

124

you understand why you're taking it.

125

There are so many people taking a

proton pump inhibitor that are taking

126

it for either the wrong reasons or for

reasons that they don't understand.

127

So maybe your doctor put you on it

years ago and has never reviewed

128

it and never checked it with you.

129

Some research, which was from about 20

years ago in the UK, so I don't actually

130

know if these numbers have gone up or

down to be fair, but about 25 to 75

131

percent of people were taking PPI's

inappropriately, which could be a huge

132

drain on the NHS, but also on your health.

133

It's not without consequence to

take something which suppresses

134

your acid in your stomach because we

actually need it for our digestion.

135

So whilst there are those cases that

I've said who, people who must carry

136

on taking it, there are a lot of people

taking it who don't need to be taking it.

137

So if You are not sure whether

you should be taking a PPI or not.

138

I definitely think it's worth

reviewing it with your doctor.

139

For most cases of reflux or esophagitis,

proton pump inhibitors should be

140

taken for around 4 weeks or 6 weeks.

141

And yet, a lot of people I work with

have been taking them for years and

142

don't actually really know why they're

taking them or why they're taking them.

143

What would happen if they stop?

144

So whilst I definitely don't recommend

stopping without doing some of

145

the things I'm going to come on

to now, it's also really important

146

to just double check whether you

should be on it in the first place.

147

Some of the risks of taking a proton

pump inhibitor for a long time

148

is that we rely on stomach acid

to help us absorb key nutrients.

149

So some of the things you can be

really low in include Magnesium,

150

because we need stomach acid to

help us with magnesium absorption.

151

And when we're taking it longer term,

it's easy to become low in magnesium.

152

Magnesium is also often low when people

are stressed, which is one of the reasons

153

why We , get stomach ulcers in the first

place through high levels of stress and

154

not engaging the brain and not engaging

your normal physiology in eating.

155

Remember last week I was talking about

the vagus nerve and how you actually need

156

to do that mindful eating, the chewing.

157

These kind of things are really helpful,

but when you're stressed and you're

158

chronically anxious, you don't engage

in those behaviors, which can then lead

159

to you being prescribed a, PPI, which

blocks the stomach acid production,

160

and then you might find you are

lower in magnesium, which is actually

161

really important for managing anxiety.

162

When we're very stressed, we tend

to clench our muscles and feel quite

163

tense, and that uses up more magnesium.

164

So then again, you need more of

it and you're absorbing less.

165

Another thing you can be low

in due to blocking stomach

166

acid production is vitamin b12.

167

When stomach acid is lower it is

harder to extract b12 from foods

168

which are mostly animal products

like meat, fish, eggs, etc.

169

And without the stomach acid it

is harder to extract this vitamin

170

from the things that you eat.

171

This is quite mixed in the research, I

would say, but generally, the trend seems

172

to show that people who take PPIs over

the long term may be lower in vitamin B12.

173

The signs of low vitamin B12 are

often neurological, so things

174

like tingling, numbness in your

fingers and legs, sometimes

175

problems with cognition and memory.

176

A whole range of other things

including fatigue and brain fog

177

are also really important symptoms.

178

Another reason that taking PPIs is not

great for us longer term is that it

179

can affect your gut microbes in your

large intestine, so it can reduce gut

180

diversity, In the short term and it

may also change over the long term.

181

We know that there are links to

increased risk of Clostridium

182

difficile infection, but also just

generally reducing the diversity.

183

So when you have less types of bacterial

species in your large intestine,

184

there's more chance for those kind of

infectious pathogens to get in, make

185

your gut their home, and make themselves

at home basically in your body.

186

Then we also know that taking a PPI may

affect your chances of getting SIBO.

187

So as I mentioned in the introduction,

small intestine bacterial overgrowth

188

may be more of a risk when you have

removed one of the first lines of

189

defense, which is your stomach acid.

190

And that is one of the ways we block

pathogens from getting into the gut.

191

The stomach acid normally kills them off.

192

But if your stomach acid is reduced

in order to protect the mucous lining

193

of your gut and your stomach and to

reduce burning in your esophagus, then

194

You might be increasing the amount of

bacteria getting into the small intestine.

195

So it's not without consequence

to stop that production of acid.

196

This doesn't happen in everyone

and actually there was a study out

197

earlier this year, so quite recently,

that was shown people who took

198

Pantoprazole 40 milligrams, once a

day, it was quite a small study, only

199

38 people, and they were healthy.

200

On over 7 days, they gave them

this medication that blocked their

201

stomach acid production, and 7.

202

8 of these people developed Or they

developed symptoms like bloating

203

and gas and an increase in bacteria

in their small intestine, which

204

they measured with a breath test.

205

When I say it was 7.8% is actually

two people out of 38, which also means.

206

92 percent didn't get SIBO.

207

Okay, so I don't want people to take all

these, research studies out of context.

208

The way the information is

presented can be very leading and

209

guide you to certain, conclusions.

210

So the researchers obviously here are

trying to suggest that people shouldn't

211

take PPIs because it's a risk of SIBO.

212

Whilst that is true, that yes, two people

out of 38 did end up with increased

213

bloating and increased gas and on a

breath test had higher levels of hydrogen.

214

However, most of them didn't.

215

And when we look at it like that, it

also needs to be put into context.

216

So there's a potential

risk, but it is very small.

217

And I think there's quite a lot of

fear mongering around taking PPIs,

218

that it is definitely going to give

you SIBO, that you are going to make

219

SIBO worse if you start taking a PPI,

which is not necessarily the case.

220

If we look at actual evidence

and what the case reports and

221

research studies are showing us.

222

The other thing that might be affected

by taking a PPI is your iron absorption,

223

because again, it normally relies on a

certain pH level to best absorb iron.

224

When your proton pump inhibitor

is blocking acid production,

225

you may absorb less iron.

226

Now iron can also, transport

oxygen around the body.

227

Think about those ferritin

stores that are so important.

228

So, making sure if you are taking a

PPI, then you should be getting regular

229

checks to make sure that your levels of

magnesium, iron, B12, and just generally

230

the rest of your, metabolic signs are all

healthy because there is a consequence

231

of having less intake of those Nutrients.

232

I just want to make sure that you

are aware of what it can do And

233

then you can take some steps to get

around it Maybe the steps are you

234

need to take an iron supplement?

235

But don't take an iron supplement

unless you know you actually

236

need to same with magnesium Maybe

your levels are low of magnesium.

237

And so taking a supplement regularly

would actually help you Linked to

238

all of these nutrient deficiencies,

there is a potential increased risk

239

of bone fractures as well on long term

acid reduction medication and that is

240

due to decreased calcium absorption.

241

So there is a potential risk for

lower bone density over time.

242

Particularly in postmenopausal women

or people who are elderly or who

243

have other factors for osteoporosis.

244

So we want to make sure that those

things have been thought about and are

245

regularly being monitored by a doctor.

246

Sometimes people will be prescribed a

PPI because they've got a hiatus hernia.

247

This is where a small bit of

your stomach goes up through the

248

diaphragm, which is a wall of

muscle that goes across your torso.

249

And your stomach is not supposed to go

above this, but sometimes it can pop up,

250

and that can also give you the symptoms

of heartburn and that irritation.

251

Not everybody who has a hernia definitely

needs to take a PPI longer term.

252

Sometimes people will be put on

a PPI and then never reviewed.

253

If this is the reason you're taking a

PPI, it might be worth thinking about

254

whether you actually need it or not.

255

I kind of wanted to end this

episode on a story of caution

256

about listening to people online.

257

So if you've been prescribed a

PPI by your doctor and they're

258

suggesting that you need to reduce

your stomach acid, it is for a reason.

259

Often it is to protect the lining of

the stomach or to get symptoms under

260

control to avoid a stomach ulcer.

261

Whatever it is, there are valid

reasons for needing to suppress acid.

262

It's not going to necessarily cure

your reason for having that ulcer in

263

the first place, but it might give

you the breathing space to enable

264

you to work on your digestion, sort

out your stress, whatever it is.

265

The PPI is more like a sticking plaster,

and plasters are helpful in some cases.

266

They give us a break.

267

Medication is there to help us and Allow

us to do the other work that is important

268

around regulating your bowel movements,

making sure your diet is good and healthy.

269

Sometimes people need to take an

antidepressant to get them through

270

a really tough time in their lives.

271

It doesn't mean that you have to take it

forever, and it's not, helpful when there

272

are people online in groups creating quite

a lot of fear around certain medication

273

and I think PPIs are one of them.

274

However, as I've been through in this,

there are consequences of taking it

275

that long term if you're not managing

it and you're not thinking about

276

it, it could lead to imbalances.

277

If you're low in iron and you're

low in B12, you could feel very,

278

very tired with brain fog and fuzzy.

279

You could be finding it hard

to get up and get motivated.

280

These kinds of things are.

281

really challenging and you wouldn't

necessarily relate it back to

282

PPI usage unless you knew that it

reduces iron and B12, for example.

283

So I hope this episode has been helpful in

just showing you some of the reality about

284

why we need to take these drugs and also

what you can do in order to monitor them.

285

Now I I have talked a little bit

about the other ones like H2 blockers.

286

They basically do very similar jobs.

287

They're both suppressing acid production.

288

People say H2 blockers are better,

but they're both doing the same thing

289

by stopping your acid production.

290

So you're going to get the same

consequences in terms of nutritional

291

deficiencies, potential increase

in changes in your gut microbes.

292

And that can happen within a couple

of weeks, whichever of these type

293

of medications that you're taking.

294

The best thing to do is to talk

to your doctor and have a good

295

and honest conversation about it.

296

And if you haven't had that reviewed for

a number of years and you've just been

297

getting it on repeat prescription, then

make an appointment to have a review.

298

In order to combat some of that

acid rebound that I talked about,

299

that happens when you stop.

300

So if you had a conversation with

your doctor, you're ready to stop.

301

Some of the things that you need

to get in place are regular meals.

302

Making sure that your diet is a good

balanced diet, that you have got

303

great sources of fibre in there,

that you are eating enough protein

304

and balancing out your blood sugars.

305

These things are really helpful because

when you come off the acid blocking

306

medication, there potentially will be

changes., not everybody gets this rebound

307

by the way as well, but it is helpful

to make sure that your body is in a

308

best place it can be before you stop.

309

So some of the things you can do is

making sure that you have worked on

310

your stress levels, you are sleeping

well, you're well hydrated because you

311

need to produce acid at the right time.

312

So you want to make sure

that That's all working well.

313

You may want to look at things like

B6 and Zinc because they are also

314

involved in stomach acid production.

315

So I'm not saying everybody should go

and take them, but you might want to

316

think about whether that is going to

be a helpful support for you as you

317

start to think about removing the PPIs.

318

There are a whole load of supplements that

also can be taken to start soothing the

319

gut lining to increase the mucus layer.

320

Things like Slippery Elm may be helpful.

321

There are also things that support

production of the mucus because you

322

want to try and regulate that as well.

323

And then, eating patterns, making

sure your mucous lining and gut

324

is well supported, and then also

that your diet is well balanced.

325

This can take a little while to get

in place, so before you do any of the

326

stopping of PPIs, you need to make sure

that you're eating well and everything

327

else is in as good a place as it can be.

328

So trying to resolve SIBO, for example,

I would suggest that you try to resolve

329

Symptoms of SIBO before you try and stop.

330

Because that can be one of the

triggers for having significant, acid

331

coming up into the esophagus where

you've got a lot of pressure and a

332

lot of gas in the torso due to SIBO.

333

It's complicated and that's why I really

suggest working with somebody who knows

334

about acid reflux, PPI's and, SIBO.

335

IBS, so someone like me, uh,

and I can do that with you.

336

So over three months I work with people

in my gut reset, and in that time I work

337

with you over six weeks talking weekly,

and in those sessions we talk about how

338

to improve your diet, how to improve

your eating pattern to maximise your

339

chances of getting a better digestion.

340

If you're interested in that, then

please drop me a line and set up a call.

341

where we can chat about what you

need help with and also how I work.

342

Thank you for listening to this episode of

the Inside Knowledge for people with IBS.

343

Better digestion for everybody.