A large and very compelling study with over 200,000
participants suggests caution for taking acid-suppressing medication (proton
pump inhibitors and H2 blockers). The study found an increased risk of death
from cardiovascular disease, chronic kidney disease, and upper gastrointestinal
PPIs have been shown to heal gastric and duodenal ulcers when used in short-term applications of 4-8 weeks. It’s important to keep an open mind about the potential benefits of these drugs. But I discourage you from taking acid-suppressing medications long term for reflux.
There are several excellent alternatives for treating the
root cause of reflux. These include dietary interventions and probiotics. In
the long run, addressing the root cause of your reflux symptoms improves your
overall health and reduces your risk of serious side effects from medication.
Episode Intro … 00:00:42 What Causes Reflux … 00:04:06 Excessive Gas Production and Bacterial Overgrowth … 00:05:21 Immune System Over-Activation … 00:07:16 Treating the Root Cause … 00:10:18 Episode Wrap Up … 00:11:48
Let’s look at what they found. The study group consisted of 157,000 users of PPIs and 56,000 users of H2 blockers. H2 blockers are a more mild form of acid-suppressing medication. They’re known as histamine receptor 2 antagonist, so they block the histamine two receptor. So we have a very compelling, very large sample size that is being tracked. Let’s look at what they found.
Conclusion: Taking PPIs is associated with a small excess of cause-specific mortality, that means death due to certain causes, including death due to cardiovascular disease, chronic kidney disease, and upper gastrointestinal cancer. The burden was also observed in patients without an indication for PPI use.
What they are indicating here is that if someone needs a PPI, it could be the underlying pathology, that underlying process in the body requiring the PPI that leads them to have that increased likelihood of death, and perhaps not the medication itself. The medication might be an innocent bystander. What they’re describing here is even those who didn’t have a clinical need for PPIs, but who were using them still saw this increased risk of specific causes of death.
Continuing their conclusion, heightened vigilance in the use of PPIs may be warranted.
That’s some pretty damning evidence urging us to be cautious with the indiscriminate use of PPIs or acid-lowering medications.
Now we shouldn’t necessarily throw the baby out with the bathwater, meaning there is good evidence for clinical utility, the ability to heal gastric and duodenal ulcers when PPIs are used for four-day weeks. So there does seem to be good evidence and we should be open-minded to a short-term application of acid-lowering medication. But it’s the long-term use and risk associated with a long-term use that we really could improve upon.
What Causes Reflux
Now what causes reflux? In my experience, the most common causes are food triggers, excessive gas production, or immune activation. Oftentimes these three are intertwined in this causal web. Now regarding dietary triggers, this is not an exhaustive list, but it’s a starting point. Things like gluten, dairy, soy, processed foods, spicy foods, caffeine, can be a problem. What one could do is perform a trial on an elimination diet.
There are different iterations of elimination diets. The six-food elimination, eight-food elimination, Paleo diet, Mediterranean diet. I like the Paleo diet because that will remove many common inflammatory or irritating foods. The good news is you only need to try this for about two to three weeks and then you should be noticing either clear benefit. If you’re not sure, that tells you that you are probably not getting to the dietary triggers or the underlying causes of your reflux.
Regarding excessive gas production, a diet that can be very helpful there is the low FODMAP diet and there has been at least one study showing that a low FODMAP diet can improve reflux or GERD, and a low FODMAP diet essentially is a diet that will limit foods that are powerful at feeding intestinal bacteria. Remember that intestinal bacteria eat some of the food that goes through your intestinal tract, and as a byproduct of eating, just like we sometimes fart and burp, so do these bacteria and they release gases and these gases can be part of what underlies GERD or reflux.
Probiotics can be helpful because they can actually help to reduce gas levels. This ties in with another potential cause of excessive gas, which could be excessive bacteria, because remember, bacteria eat substrate in the gut and as a byproduct of their metabolism, release gas.
So it stands to reason that there could be two ways in which you could rectify this problem. One, stop feeding the bacteria so much so they produce less gas. That’s the low FODMAP diet. Two, if you have too much bacteria, use a method to help reduce that bacterial overgrowth.
This is where probiotics can be quite helpful. There has been one trial showing, at least strongly suggesting, that probiotics can help to improve reflux, and there’s strong evidence showing that probiotics can help to reduce bacterial overgrowth. So probiotics, when appropriately used, and I would highly recommend our three probiotic protocol to really support the different niches in the gut that different types of probiotics can support. What the probiotics might end up doing is helping to combat this high level of bacteria with less bacteria, less gas, and less reflux.
Treatment of intestinal dysbiosis with antimicrobials
Immune System Over-Activation
Now tying back into the immune system component of this, if you have a bacterial overgrowth, we know that can irritate the immune system and cause the immune system to activate to try to crop out this overgrowth of bacteria. We also know that a low FODMAP diet can reduce immune system activation, namely through a measure on a cytokine. We see less of the inflammatory signaling molecules the immune system uses when one follows the low FODMAP diet. Also we see the same type of phenomenon when one uses probiotics. So if the immune system over-activation is the root cause of the reflux, some of these same therapies can also be helpful.
Now, how does the immune system tie in? We know that part of the signaling used by the immune system is histamine. So if we know that one of the medical treatments for reflux are histamine antagonists AKA histamine blockers. Another way of coming at this could be to use, for example, a low FODMAP diet or a probiotic, both which have been shown to lower histamine. We have preliminary evidence showing either of these therapies can improve reflux. So whether the causative factor is a food trigger, gas, or the immune system, some of these kind of keystone gut therapies, diet and probiotics, can be quite helpful in improving the underlying cause of this syndrome of reflux.
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And finally, one may want to consider a trial on a low histamine diet. A low histamine diet, instead of limiting the production of histamine as you would by going low FODMAP or using probiotics, you would actually, in this case, limit your dietary intake of histamine because some foods are higher in histamine than others.
Treating the Root Cause
So if we zoom way out, fairly compelling evidence that we should be very cautious with the long-term use of assets oppressing medication, whether that’s a PPI or an H2 histamine blocking agent. Fortunately, things like diet and looking at the use of probiotics can be very helpful in not only reducing the symptoms of GERD or reflux but also helping to fix the underlying cause of that symptom. Because remember, we want to use our interventions to get to the root cause, not just suppress the symptom, and I think it’s fairly tenable to argue that a PPI or a histamine antagonist is not really treating the cause of the problem.
Now, there is certainly a time and a place for symptomatic palliative measures. However, if we can get to the root cause of the high histamine levels by using a diet that reduces inflammatory foods or a low FODMAP diet, which reduces both gas and histamine, or by using a probiotic which can reduce gas and histamine production. Now what we’re doing is opening up the chance to see not only a reduction in the chief complaint of reflux, but you may sleep better. You may have less joint pain, you may have clearer skin, or you may have clearer thinking. As an example, we know that when histamine levels are too high, that can be correlated with impairment of cognition. People can feel kind of foggy when histamine is high, just as one of many examples.
Common Causes of Reflux
Immune activation i.e. histamine
So in summary, caution with long term use of acid-suppressing medication is quite warranted. Fortunately, there are other therapies that can be used, namely an elimination diet, like Paleo or low FODMAP and probiotics are some very simple interventions that one can use to get to and address the root cause of the reflux, for us not needing an acid-lowering medication, and potentially even reaping side benefits like less joint pain or improve cognition as a byproduct, again, of treating the underlying cause of the imbalance. So hopefully this helps you get healthy and get back to your life and find a way to get off of an acid-suppressing medication.
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