The perils of proton pump inhibitors - Part 3

PPIs do more harm than good in most people who are taking them, but what is the best way to stop these drugs to avoid rebound symptoms?

Jan 25, 2024

In Part 1 of this series on proton pump inhibitors (PPIs), I covered the basics – how these drugs work, what they’re supposed to be prescribed for, and the deeply concerning rate of inappropriate use of these medications.

In Part 2, I examined the known and suspected adverse effects of PPIs, and some of the mechanisms which drive these harms.

In this final instalment in the series, I’ll outline how to stop taking PPIs safely, and how you might go about repairing any damage they might have caused.

Decision time

When should you think about stopping a PPI? In a nutshell, if:

You don't have a clinical indication for using one (that is, you're not suffering from the short list of conditions for which PPIs have been found to be effective - see Part 1). Given the evidence summarised in Part 1 that up to 84 per cent of people taking a PPI are doing so inappropriately (no indication, incorrect dose, long-term use when short-term is all that's required), there's a very good chance that you fall into this category.
You have not implemented lifestyle changes (discussed in detail below) that are known to decrease the underlying promoters of reflux and its most serious long-term complication, cancer of the oesophagus. PPIs do not address these underlying factors, and in fact, long-term PPI use appears to substantially increase the risk of oesophageal cancer.
You are at high risk of, or are already experiencing, any of the serious adverse effects of PPIs described in Part 2.

How to stop taking a PPI

If you've read Part 1 and Part 2, you might be tempted to just stop taking your PPI. That's not necessarily a good idea. As a study of healthy volunteers with no reflux-related disease found, as little as eight weeks of PPI treatment can cause oversecretion of the stomach hormone gastrin, which results in rebound acid hypersecretion, and acid-related symptoms, after abrupt cessation of the drug.

Yes, you read that correctly. The drug that you were taking to suppress acid reflux can trigger worse symptoms if you suddenly stop taking it. No wonder so many people end up taking these drugs for years! Fortunately, slowly tapering the dose of a PPI allows most people to eventually stop taking the drug altogether without their symptoms returning.

Here's how to taper off a PPI:

Step 1

Share the deprescribing resources listed below with your doctor, and ask him or her to assist with your PPI taper by prescribing the next lowest dose of the medication you're currently taking. Usually, this will be half your current dose. Stay on this reduced dose for 4-8 weeks, depending on how long you've been taking a PPI.

You can use any of the following for symptom relief during a PPI taper, and to treat the underlying cause/s of the condition for which you were prescribed a PPI:

Zinc L-carnosine. This specific formulation of zinc has a slow dissociation rate in the stomach, meaning that it hangs around there for a prolonged period, where it can exert therapeutic effects on inflamed and ulcerated tissue.
Zinc L-carnosine has been shown to prevent gastric ulcers and improve their healing rate in both animal and human studies. Not only does it adhere to ulcers, but it builds up the zinc content of surrounding tissues.
It also blocks the adhesion of Helicobacter pylori to the stomach wall, inhibits H. pylori-mediated gastric inflammation, and improves H. pylori eradication rates when added to standard triple therapy.
Zinc L-carnosine blocks aspirin-induced injury of the gut mucosa.
You might remember from Part 1 that gastric ulcers, H. pylori-associated disease and nonsteroidal anti-inflammatory drug-induced ulceration are three of the indications for PPIs. Given the excellent safety profile of zinc L-carnosine, people who have been prescribed a PPI for treatment of gastric ulcers, H. pylori-associated gastritis or ulceration, or during prolonged used of NSAIDs, might consider a trial of this nutraceutical before they resort to taking PPIs.
Iberogast. This herbal combination contains standardised extracts of nine plants traditionally used for digestive discomfort. Iberogast has been used in Germany for over 50 years for treatment of functional gastrointestinal disorders. Many people who are prescribed a PPI without one of the proper indications listed in Part 1, are actually suffering from functional dyspepsia. There are many trials demonstrating the efficacy of Iberogast for relief of functional dyspepsia. Importantly, Iberogast addresses the underlying drivers of functional dyspepsia - disturbed gastrointestinal motility, visceral hypersensitivity, microbial dysbiosis, gut inflammation and gastric hypersecretion - so the relief gained after a course of treatment is quite durable.
Deglycyrrhizinated licorice root (DGL). Licorice root has a long history of traditional use for treatment of indigestion and peptic ulcers. Unfortunately, a constituent of licorice called glycyrrhizin can, with prolonged intake, reduce blood potassium levels leading to abnormal heart rhythms, high blood pressure, oedema, lethargy, heart failure and hypokalaemic myopathy manifesting as flaccid paralysis.
Deglycyrrhizinated licorice root (DGL) is a licorice preparation from which glycyrrhizin has been removed, making it safe for extended use. DGL has been found to be effective for functional dyspepsia
Licorice root
Limosilactobacillus reuteri Protectis®. Formerly known as Lactobacillus reuteri DSM 17938, this probiotic strain has been shown to reduce infantile colic (a frequent cause of inappropriate PPI prescription in babies), treat functional abdominal pain in children, and when combined with a PPI but without antibiotics, to eradicate H. pylori in some individuals.
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Step 2

If your reflux symptoms are manageable, reduce your PPI dose by half again, and stay on this reduced dose for another 4-8 weeks, before halving the dose once again.

Step 3

Once you're on the lowest available dose, you can either

Stop taking the PPI altogether; or
Take a PPI on a demand basis - that is, only when you have reflux symptoms... which should be very rarely, if you follow the diet, lifestyle and gut microbiome restoration advice below; or
Switch to a H2 blocker such as cimetidine or fanitidine (ranitidine, a popular H2 blocker sold as Zantac, was suspended in 2020 due to contamination with a potentially cancer-causing substance).

You can continue to use any of the adjunctive therapies listed above, to reduce the risk of relapse while you implement...

Lifestyle modification for gastroesophageal reflux disease (GORD/GERD)

If you want to get off PPIs and never have to take them again, you're going to have to get serious about addressing the underlying cause/s of the symptoms that drove you to take a PPI in the first place:

Adopt a wholefood plant-slant diet, high in fibre and relatively low in fat.
This dietary pattern - in which whole or minimally-processed fruits, vegetables, whole grains, legumes, nuts and seeds provide the bulk of calories - will help you lose weight if you need to. Weight loss reduces and can even eliminate GORD symptoms.
High dietary fat intake is associated with an increased risk of both the symptoms of GORD, and erosive oesophagitis. The presence of dietary fat in the small intestine increases the frequency of transient relaxations of the lower oesophageal sphincter (the ring of muscle which is supposed to close off the stomach from the oesophagus, except when you swallow) in people with GORD. Most reflux episodes occur during these transient relaxations, so the less fatty your diet, the less heartburn you'll suffer.
Conversely, high fibre intake is associated with a decreased risk of GORD symptoms, and increasing the intake of fibre - in particular, soluble fibre - reduces the frequency of heartburn and the number of reflux episodes, as measured by 24 hour oesophageal pH-impedance.
Avoiding eating large meals, especially at night.
You're far more likely to experience indigestion and heartburn after eating a large meal, but the later in the day you eat the meal, the more likely it will trigger your symptoms, because the human gut has a strong circadian rhythm. All of its digestive functions (saliva, acid, enzyme and hormone secretion, and muscle contractions) become less efficient as the day wears on, increasing the likelihood of reflux - not to mention other functional gastrointestinal disorders such as IBS. People who go to bed within three hours of finishing dinner, have a more than seven-fold higher odds of experiencing GORD than people who have a four hour or longer dinner-to-bed time.
Quit smoking. As if you needed another reason to dispense with this costly and destructive habit. Nicotine reduces lower oesophageal sphincter pressure and increases acid reflux events.
Check the adverse reactions of any other medications that you're taking; many of them are known to exacerbate GORD symptoms. Antibiotics, oral bisphosphonates, iron supplements, ibuprofen and aspirin, anticholinergics, tricyclic antidepressants, calcium channel blockers and nitrates, opioid narcotics, progesterone, benzodiazepines and theophylline are all potential culprits.

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While you're working on addressing underlying causes, you may also need to remove reflux triggers from your daily routine:

Identify and temporarily avoid reflux-triggering foods. If you're adopted a low-fat wholefood plant-based diet but are still experiencing GORD symptoms, eliminate the following common reflux triggers from your diet, and then add them back (one 'new food' every 3 days) to pin down the culprits in your particular case:
- Spicy foods
- Alcohol
- Onions
- Tomatoes
- Apples
- Oranges and their juice
- Nuts
- Carbonated beverages
- Coffee
- Black tea
- Chocolate.

You may be able to reintroduce these foods eventually, as you work on resolving the underlying causes of your reflux.

Avoid lying down within 3 hours after a meal, or bending or straining (e.g. weight lifting or heavy gardening).
Elevate the head of the bed by 10-15 cm. Prop it up on a couple of house bricks or stacks of timber; propping yourself up with pillows doesn't work.

Correcting gut dysbiosis after PPI use

As mentioned in Part 1, PPIs cause significant disruption to the gut microbiota, especially in the small intestine. Taking a PPI increases the odds of developing small intestinal bacterial overgrowth (SIBO) by 70 per cent.

If you are experiencing symptoms such as abdominal bloating and distention, excessive gas, and either diarrhoea or constipation during or after taking a PPI, it may be worth undergoing testing for SIBO, and treating it using appropriate probiotics, prebiotics and/or herbal antimicrobials if you are found to have it.

Even if you don't have post-PPI SIBO, you're still likely to have a significant degree of dysbiosis which you should address through eating a diverse, high fibre, wholefood, plant-rich diet; getting regular exercise (preferably outdoors, in nature, to harness its beneficial effects on your microbiome); adopting an optimal pattern of meal timing (large breakfast, medium-sized lunch and small dinner, eaten as early as possible); and, if appropriate to your circumstances, periodic short (i.e. 2-3 day) water-only fasts and/or time-restricted eating (confining eating to an 8-10 hour 'window', e.g. 8 am to 6 pm).

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We've had a gutful of PPIs

In summary, proton pump inhibitors are just the latest in a long line of 'wonder drugs' which were released onto the market with the promise that they were highly effective and very safe, and hence quickly outstripped their initial prescribing indications to the point where if a person walked into a doctor's office complaining of any kind of tummy upset, they were likely to walk out again with a prescription for a PPI.

The initial fanfare of enthusiasm for PPIs has now quietened into muted background music, and may in time transform into a dirge as research brings to light the full extent of the impact of these drugs - especially their deleterious effects on the delicate balance of gut bacteria which plays such a huge role in our physical and psychological health.

In the mean time, it's up to each individual to take responsibility for their health, and this includes quizzing their doctor about the cost-benefit analysis of each of the drugs they've prescribed. The following resources are useful sources of information to share with your doctor when discussing the possibility of discontinuing a PPI.