Ppi rebounding

[HEARTONMYSLEEVE 1]

I have been reading so many people on here afraid of going off their PPI's and then when they do the acid is still there. I actually remembered hearing an article a couple of years ago on NPR about PPI rebounding and went online to see if I could find this information anywhere. I found an article and thought I would post it for you guys. Hope its helpful. But the basically when you come off the PPI's the stomach acid rebounds and produces, at least at first, more than you started with. So I would think it's important to give going off the PPI more time before you go running back to save yourself from the burning.

How to Survive "Acid Reflux Rebound"

PPI drugs are supposed to be used for a restricted period of time, however most patients continue their use indefinitely. Not only do patients abuse these drugs, but also the physicians who prescribe them. There are no studies regarding the long term use of PPIs. One has to question whether their prolonged use is really safe. Fortunately, there are natural ways to survive "acid reflux rebound".

There are many people who suffer from acid reflux and want to get off the proton pump inhibitor drugs (PPI drugs). The main action of this group of pharmaceuticals is the long acting reduction of gastric acid production. These include Prevacid, Prilosec, Nexium and Protonix.

These drugs are convenient to use and can be initially useful, but many find that the side effects outweigh the benefits. When it comes to quitting them, one will find that it is not so easy.

PPI drugs are supposed to be used for a restricted period of time, however most patients continue their use indefinitely. Not only do patients abuse these drugs, but also the physicians who prescribe them. Unfortunately, there are no studies regarding the effects of the long term use of these drugs. One has to question whether the prolonged use of PPI drugs is really safe.

We do know that by reducing the production of stomach acid, the proper digestion and assimilation of food is restricted. Are chronic users of these drugs suffering from a form of malnutrition? It is important to keep in mind that stomach acid also keeps potentially dangerous intestinal bacteria in check. So what may seem to be acid reflux utopia, in reality may be acid reflux hell.

When one stops these drugs, after prolonged use, the acid pumps turn on again and come back with a vengeance producing more acid than they did before. This is referred to as "acid reflux rebound". This is often such a terrible and frightening experience that most people become quickly discouraged and immediately get back on the drugs. This "catch 22" situation has proven to be a virtual gold mine for the pharmaceutical companies, who make billions of dollars in profits each year.

It is a horrible position to be in. You know you want to quite these drugs. They stop working and you are instructed to double the dose. You make an effort to stop, but it all backfires on you. Your throat burns like its on fire and your doctor tells you that if you don?t take the drugs you may develop esophageal cancer. Who wouldn?t be frightened?

Now for the good news; there are non-pharmaceutical things that one can do to survive "acid reflux rebound" and get back on the right track.

At this point there is most likely damage to the esophagus. One cannot hope to improve until the esophagus is well again.

In order to heal the esophageal damage, there are a few things to be considered. First and foremost one must temporarily change their diet. By now everyone should be aware of what foods and beverages trigger their acid reflux. Replace these offending foods with mild, easy to digest foods.

Instead of a slice of pizza with acidic Tomato sauce, have a salad. Substitute that morning cup of coffee with a cup of tea. Have a glass of white instead of red wine with dinner. It?s just a matter of common sense, but these changes are necessary during the acid reflux recovery period.

In order to defeat the acid reflux syndrome, one must attempt to become as alkaline as possible. Anything which has an acidic effect on the body should be eliminated. Smoking is perhaps the most acidic thing one can do. Eating too much at one time causes an over production of stomach acid. Aerobic exercise actually causes the body to become more alkaline in nature.

Drinking copious amounts of clean fresh Water will help flush out the acidic toxins which accumulate in the body. A body which is properly hydrated is rarely acidic in nature. A glass of Water after a meal is a good idea, but drinking much of anything with meals is counter productive. This dilutes the digestive fluids, causing the stomach to produce more acid.

Believe it or not, chewing gum between meals is beneficial. Chewing produces saliva which is very alkaline. Chewing gum after meals puts more alkalinity in the stomach to counteract the over production of acid.

There are many natural ingredients found in grocery and health food stores, which can help during the acid reflux recovery period. Herbs, such as marshmallow and slippery elm have wonderful healing properties. Licorice, natural honey and aloe vera juice can sooth the esophageal lining and assist in the healing process.

There are very few cases of acid reflux which can?t be successfully treated if one understands what causes this condition. Simple things like eating slowly and chewing food thoroughly, in a pleasant relaxed atmosphere, can reduce ones chances of having acid reflux.

We do not have to be prisoners of this drug oriented "acid reflux rebound" effect. It is unfortunate that most doctors rely on pharmaceuticals as the only solution to the acid reflux condition.

With a little education regarding the causes of acid reflux and the knowledge of natural medicine, one can survive "acid reflux rebound" and go on to live a normal life. We are at the brink of a new era where the patient must sometimes also be the healer.

? 2007 Wind Publishing

By Crystal Phend, Staff Writer, MedPage Today

Published: July 02, 2009

Reviewed by Zalman S. Agus, MD; Emeritus Professor

University of Pennsylvania School of Medicine and

Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner

Earn CME/CE credit

for reading medical news

SAN FRANCISCO, July 2 -- Proton-pump inhibitors may cause or aggravate the very acid-reflux symptoms they're used to treat, according to a randomized trial. Action Points

Explain to interested patients that the study supported the hypothesis that PPI treatment induces compensatory mechanisms that result in rebound acid secretion after discontinuation of therapy.

Note that the study included only asymptomatic, healthy individuals, who may differ from symptomatic patients in important ways.

After a two-month course of esomeprazole (Nexium), 44% of asymptomatic, healthy volunteers had clinically significant heartburn, acid reflux, or dyspepsia, compared with 15% who had taken placebo (P<0.001), according to researchers led by Peter Bytzer, MD, PhD, of Copenhagen University and K?ge University Hospital.

This apparent rebound acid secretion, to a point above baseline levels, could lead to PPI dependence, the group reported in the July issue of Gastroenterology.

Treatment guidelines support the typical primary care practice of initiating a trial of PPI treatment empirically for dyspeptic symptoms, the researchers said.

However, up to a third of these patients keep taking the drug in the absence of symptoms, with physicians in some studies reporting that withdrawal or dose reduction in long-term PPI use is hard to achieve.

"Thus, patients with ambiguous symptoms that are not truly acid related may be prescribed a PPI empirically, but may find it difficult to withdraw from therapy because of the development of true acid-related symptoms," the researchers said.

The hypothesis, though controversial, has been that PPIs perpetuate symptoms and necessitate their continued long-term use.

The proposed mechanism for this so-called rebound acid hypersecretion is that elevated gastric pH caused by blockage of the proton-pumps stimulates compensatory mechanisms leading to increased capacity to stimulate gastric acid secretion.

Dr. Bytzer's results supported this theory. Symptoms in the PPI group continued, even in the final week of the study, after gastric acid suppression measured by plasma gastrin levels had normalized, with sustained elevation in the acid secretory capacity reflected by chromogranin A levels (P=0.02 at week 12 versus baseline).

In an accompanying editorial, Kenneth E. L. McColl, MD, and Derek Gillen, MD, both of the University of Glasgow in Scotland, said the findings should challenge current "liberal" prescribing habits.

Among their recommendations:

Restrict PPI use to patients likely to derive benefit, such as those with symptoms accompanied by endoscopic evidence of erosive esophagitis or of increased esophageal acid exposure.

Limit the PPI trial to one or two weeks as a diagnostic test for possible acid-related symptoms to reduce the chance of inducing hyperacidity and associated symptoms.

Adopt a "step-up" approach rather than "step-down" from medications to lifestyle alterations and milder medications such as antacids or alginates.

Inform patients about rebound acid hypersecretion and its potential effects as part of the discussion about side effects and safety.

To prove that the "acid rebound" symptoms were not simply a relapse of symptoms from underlying disease, Dr. Bytzer's group conducted a double-blind, placebo-controlled trial in 120 healthy volunteers without any prior acid-related disease, symptoms, or treatment.

These participants were randomized to receive 12 weeks of placebo or eight weeks of esomeprazole 40 mg/d, followed by four weeks of placebo.

None of the symptoms reported on the Gastrointestinal Symptom Rating scale questionnaire patients filled out each week was different between groups through week eight.

But after the PPI group discontinued therapy in week nine, their dyspepsia and reflux syndrome scores on the gastrointestinal-specific scale climbed in comparison with the placebo group.

For weeks nine through 12, the esomeprazole group had significantly higher overall mean combined dyspepsia and reflux syndrome scale scores (1.35 versus 1.12, P<0.001) and isolated reflux syndrome scale scores (1.36 versus 1.13, P=0.009).

The only individual symptoms with elevated incidence at week 12 among PPI-group participants compared with placebo-treated subjects were heartburn (difference 12.1%, P=0.006), acid regurgitation (difference 10.3%, P=0.013), and dyspepsia (difference 12.1%, P=0.017).

Other symptoms included on the questionnaire, such as indigestion, Constipation, and diarrhea, were not different between groups.

The typically mild to moderately severe reflux symptoms showed up within the first two weeks after discontinuation of esomeprazole for the majority of patients.

The duration of the rebound symptoms, however, was unclear because they were still present at the end of the monitoring period four weeks after discontinuing the treatment.

The researchers acknowledged that the symptoms seen in these healthy individuals could differ from those in symptomatic patients.

"On the other hand, rebound acid hypersecretion could be even more relevant in patients with reflux disease or other acid-related disorders," they said, if those patients find it difficult to quit PPIs because of rapid recurrence of symptoms aggravated or even provoked by rebound acid hypersecretion.

The study was funded by the Danish Medical Research Council, K?benhavns Amts Research Foundation, and Region Sj?llands Research Foundation. The study medication and placebo were provided by AstraZeneca.

Dr. Bytzer reported conflicts of interest with manufacturers of proton-pump inhibitors -- AstraZeneca, Wyeth, Nycomed, and Eisai. A co-author reported conflicts of interest with Wyeth.

The editorialists reported no conflicts of interest.

[stcyt 15]

Interesting heartonmysleeve

I was perscribed ppi's for 60 days as a preventative measure. I have experienced zero acid. I wonder if I'm askng for trouble

[Tiffykins 672]

Thanks for posting as I am on of those that will not go off my Prilosec in fear of having issues.

I think my "anxiety" with going off of it is the sheer fact that it took me months to feel good. I was sick for a long time, and I have been thriving and do not want to regress back to being sick.

I have a follow-up with my surgeon for my 1 year later this month or in June. I will discuss some options. I may go to one dose every other day, but I'm just not willing to be "sick" again.

I'd be willing to use some natural remedies, but I'm not willing to set myself up for pain and discomfort.

[ouroborous 519]

Well, even without reading the research, I assumed that there were homeostatic mechanisms that would lead to a "rebound" effect when coming off the acid blockers.

My intent for a long time has been to take the PPI's for a "while" (3-6 months, say), and then, under doctor supervision, begin a process of weaning off them. This just firms up my intentions.

[Swiftflow 6]

Hmm interesting. I started the PPI on day 3 at advice of the doc--but I never had acid issues the two days prior to starting. Anyone think I should try without them for a bit to see if acid is even an issue before creating a situation in which they will be needed?

[cajun 46]

THANK YOU for these excellent reports. I was aware of this when I started taking the PPI after surgery, and decided to continue taking the PPI for three or four months, to give my stomach the best chance to heal.

Then I switched to OTC Zantac, which allows the proton pumps in the stomach to go ahead and resume pumping out acid, at the higher than usual rate, as described in the studies. But the Zantac neutralizes the effect of the acid. This is a sort of "step down gently" program, and it seems to be working for me. Some days I don't take the Zantac, and will be weaning off it within the next few months.

Carbohydrates seem to cause me to have more acid symptoms. So I know what to avoid. My goal is to not need any medications at all...but I am doing all this with the supervision of my gastroenterologist.

PPIs are great when needed, but even the companies that make and profit GREATLY from selling them say that they should only be taken for a short period of time. They did cause cancer in rats when given at really high doses during the pharmacologic studies before the drug was approved by the FDA. I'm not a rat, and did not take those high doses...but better safe than sorry!

Thanks again!

[Tiffykins 672]

Hmm interesting. I started the PPI on day 3 at advice of the doc--but I never had acid issues the two days prior to starting. Anyone think I should try without them for a bit to see if acid is even an issue before creating a situation in which they will be needed?

I didn't have acid issues for nearly 6 weeks post-revision, and never had acid issues pre-op even with my band.

I didn't let it get to the point of true acid coming up my throat. It was a funky, twinge in my stomach after eating.

It took several days like 7-14 days for the Prilosec to kick in and resolve the issue.

I'll definitely discuss this with my surgeon, but I'm such a baby when it comes to how I feel. Any sign of something not being "right" sends me over the edge with anxiety and worry. I thank the Lord above for an amazing surgical/medical team that truly understands why I am so paranoid about getting sick again. They may roll their eyes when I'm not around, but when I need them they are there to get me through it without making my concerns seem trivial.

[LAN2k 18]

Good article. This is a very important issue and warrants further investigation. A friend of mine told me from the get-go how necessary stomach acid is for proper digestion and protection from bacterial infection like H-Pylori. What I don't understand is why H-pylori is treated with a PPI along with aggressive antibiotics! I had a few bouts with acid reflux within the first couple of weeks after my surgery. My surgeon initially sent me home with a script for otc pepsid ac. That did not work. I tried prilosec but the side effects of overnight dried mouth and tongue and the lucid insane dreams caused me to stop taking it. I tried protonix but that also produced side effects that I had trouble with. Since my surgery I would gag and heave every morning as I was brushing my teeth and rinsing. It was as though I had some lining of mucus in my throat that could not be expelled and it would be aggravated by the gargle and I'd gag. Later I read in one of these threads that sometimes acid reflux symptoms manifest as excessive mucus production, as the body's way of protecting tissue from the acid. The person who posted this backed it up with a scientific article and she also stated the PPI she was put on and that after taking it her symptoms ceased. Well, so I contacted my surgeon and PCP had them both read the article and without any resistance was given a script for the PPI Aciphex, for which there is no generic to date. I take one 20mg per day. I'm no longer gagging and dry heaving when I gargle in the morning but I still have that back of the throat mucus and NOTHING seems to alleviate it. Often times my throat is sore from futile attempts at clearing it. I am now wondering if it is due to acid reflux even if I'm not having the ordinary symptoms and am taking athe PPI Aciphex. I hope I can find relief and that soon things will regulate in my body.

[stcyt 15]

Hmm interesting. I started the PPI on day 3 at advice of the doc--but I never had acid issues the two days prior to starting. Anyone think I should try without them for a bit to see if acid is even an issue before creating a situation in which they will be needed?

I'm wondering the same thing. If its not broken why fix it?

[HEARTONMYSLEEVE 1]

Just so everyone is clear I am not against PPI's. I was given pepcid after surgery and was still having acid issues so I asked the doctor what we could do and was given a RX for Protonix. Still not sure the Protonix is working either not that I have reflux but I feel hungry a lot which apparently can be from too much acid in the stomach. I think if your doctor wants you to take a PPI then you should. We just need to remember that they are for short term use. Also, I really wanted to make people aware of the rebounding effect they have so we don't get so scared coming off of them that we end up right back on them again. I think many people don't realize that's what happens and think that their reflux has gotten worse or is still there when really they need more time off the drug to find out if their reflux has resolved or improved. From what I've read the best way to stop taking them is gradually and then take acid reducers like pepcid or tums as needed while watching your diet for trigger foods until the rebounding effects are over. I think the PPI's are definitely very helpful in the beginning stages as I was sleeping sitting up a couple of nights it got so bad. Although it may not be a bad idea to start like I did on the pepcid and see if you really need the PPI if you doctor likes that route.

[LAN2k 18]

Besides acid reflux I was under the impression that excess stomach acid could be a cause of ulcers? Info on that anyone?