One of the most challenging, yet beautiful, things about medicine is that doctors are always changing their minds. There’s a saying in medical school: “Fifty percent of what we teach will be proven wrong at some point in the future.” And it’s not for lack of trying or lack of caring! It’s because we care so much. That’s why we stay on top of the latest research, and as scientists, experts, and think tanks pump out information and recommendations, we update our practices to reflect what science tells us is best today. We change our minds.
A great example of these waves of change in medicine is the management of GERD: gastroesophageal reflux disease.
GERD: A crash course
So, what is GERD? It stands for gastroesophageal reflux disease, which is a fancy way of saying that stomach acid is seeping through the lower esophageal sphincter (the aperture between the stomach and the esophagus) upward where it doesn’t belong — into the esophagus and sometimes even the mouth. It can manifest as heartburn, abdominal pain, chest pain, nausea, low appetite and a sour, acidic taste in the mouth known as “water brash”.
GERD? We’ve got drugs for that.
Doctors love to make people feel better. It’s probably the number one reason we go into medicine. So it shouldn’t come as a surprise that when effective drugs came on the market to treat GERD, they were prescribed ad nauseum. As such, drugs for GERD presently rank second (after antidepressants) for the most commonly taken prescription drug in Canada in men aged 25-44, and fourth for women in the same age group.
Since their introduction to the pharmaceutical market, there’s been a frenzy in prescribing a class of GERD drugs called Proton Pump Inhibitors (PPIs), the “–prazole” drugs; pantoprazole (Tecta), omeprazole (Losec), esomeprazole (Nexium), etc.
You might be thinking,“Hey, I take that!” Great news is they effectively control symptoms, allowing you to eat your favourite menu items like pepperoni pizza, red wine, tiramisu, and a coffee to top it off.
But there’s a catch (you saw that coming, right?).
The risks of long-term PPI use
We’ve learned that “prazole” drugs aren’t without their side effects and long-term risks. They treat GERD by reducing the amount of acid present in your stomach (lessening acid production by about 66% and keeping it lowered for up to 48 hours). But acid’s there for a reason — it helps digest food. And by messing with acid production, we’re interfering with normal digestion and absorption. This leads to one of the most common risks of this medication, which is nutritional deficiency, especially of magnesium, calcium, vitamin B12 and iron, which are essential for healthy brains, hearts, bones, muscles, and more.
PPIs also increase your risk of developing a severe diarrheal infection called C. difficile colitis. This can result in dehydration, hospitalization, and even death. We’re also seeing patients with a type of gut or colon inflammation called “microscopic colitis” which can cause chronic abdominal pain, diarrhea and even rectal bleeding. In short, PPIs can cause very unhappy guts.
Some studies have also linked PPI use to development of pneumonia, dementia and even death. One such study in the British Medical Journal (BMJ) followed over a million US veterans, including over 300,000 who were prescribed PPIs, over a 5-year period. When numbers were crunched, those prescribed PPIs were more likely to die than their non-PPI counterparts. Even when comparing PPI users to those prescribed a different type of GERD medication (such as an H2-receptor blocker like Ranitidine or “Zantac”), PPI users were more likely to die — 25% more likely.
Now I’m not saying that PPIs are never indicated, but they’re over-prescribed. The problem is compounded when patients are not weaned off those prescriptions, leaving them on PPIs for long-term use. And the data tells us that the longer you’re on a PPI, the higher your risk of complications. For occasional reflux, PPIs are overkill. Lifestyle changes should always be made, and less risky medications tried first if prescriptions are indicated.
I want OFF my PPI. What next?
Your PPI was prescribed for a reason. Go back to your prescriber (or your family doctor if your prescription originated from a one-night stand with an ER doc) and find out whether or not it’s still a good choice for you.
Do NOT stop cold turkey. You can get rebound heartburn and reflux. A good strategy is to skip one pill weekly, taking 7 weeks to wean yourself off completely (skip Monday in week one, skip Monday and Friday in week two, skip Monday, Wednesday, Friday in week three, etc.) — but only with your doctor’s recommendation.
Finally, you can’t have your cake and eat it too … I should say, you can’t eat anything you want AND ditch the drugs if you suffer from GERD. Try to make better dietary choices (most of the time), and learn, and avoid, your triggers. Some of the most common triggers for people with GERD are:
- Smoking (cigarette smoke is super-irritating to the stomach and esophagus). Get help to quit!
- Being overweight (it puts excess pressure on the sphincter or valve between your esophagus and stomach, allowing upward reflux of acid where it doesn’t belong).
- Eating greasy and fatty foods, including meats and high fat dairy. Some studies suggest these foods can relax the same sphincter, allowing acid to go where it doesn’t belong.
- Drinking soft drinks and carbonated beverages.
- Eating less than 2 hours before bed (when you lie down, your stomach contents and the acid that’s working on digestion can creep upward).
- Citrus. Spicy food. Coffee. We used to recommend avoiding all of these, but some are less bothersome than we thought. Monitor your own triggers and make adjustments as required.
- NSAIDs (ibuprofen or Advil, naproxen or Aleve) are very hard on the stomach. They can play a part in your stomach symptoms.
Treat GERD naturally with licorice
My favourite PRN (latin for “as needed” — check it out on your next doctor’s Rx) pill to quell occasional heartburn? Licorice. Not Twizzlers, rather a natural supplement called “DGL” or Deglycyrrhizinated Licorice.
Licorice has been used for centuries in traditional Chinese and herbal medicine. Studies in modern conventional medicine are lacking, but this is one of those cases where long-time usage, along with an excellent safety profile, makes it worthwhile to try.
Licorice is a “demulcent”, meaning that it interacts with the lining of our gut (all the way from mouth to bum), creating a protective barrier. It soothes the stomach and esophagus and helps the gut heal.
Practical tips for using DGL for GERD:
- Chew two to four tablets (~350mg DGL/tablet) up to thrice daily as needed for GERD. Chewing mixes DGL with saliva, increasing its efficacy.
- Keep a bottle in your medicine cabinet, purse or car for immediate relief
- Take DGL before a meal to prevent GERD, if you plan to eat one of your usual triggers
- Use DGL while you’re weaning from your PPI (they’re safe in combination)
Is it safe? In its whole or root form, licorice can cause problems related to potassium balance in the body, so it should be avoided by those who have high blood pressure, kidney disease, diabetes or heart disease, or those taking warfarin, corticosteroids, digoxin and high blood pressure pills. DGL is different because the glycyrrhizin (which is the usual culprit in these interactions) has been removed, so it’s generally considered safe. But, as always, if you take regular medicines or have other health conditions, talk to your doctor before taking. Avoid in pregnancy and breastfeeding.
Symptoms it’s more than just GERD
Red flags which should make you think there’s something more going on, such as an ulcer (or worse, the “C” word):
- unintentional weight loss
- rectal bleeding or black stools (known as melaena)
- night sweats
- new GERD symptoms starting after the age of 50
- GERD symptoms if you’re a smoker
Any of these checks fulfilled should bring you to your doc’s office.
Arm yourself with the knowledge and natural strategies you need to battle GERD. Talk to your doc about going drug free (if you’re on a PPI) and for when an indulgence gets the better of you and of your lower esophageal sphincter — your licorice awaits.
Want to learn more about optimizing your health and wellness? Sign up to be notified about new blog posts.
Website terms and conditions here.