ulcers Archives - Granite Peaks Gastroenterology of Utah

How Safe Are Proton Pump Inhibitors?

Posted on July 12, 2016December 27, 2024 by fuelmarketing

By Dr. Christopher Cutler

Proton pump inhibitors (PPIs) are medications used to treat acid-peptic disorders such as gastroesophageal reflux disease, gastritis, and peptic ulcer disease. There are several PPIs on the market including Prilosec (omeprazole), Prevacid (lansoprazole), Nexium (esomeprazole), Aciphex (rabeprazole), Protonix (pantoprazole), Dexilant (dexlansoprazole), and Zegerid (omeprazole and sodium bicarbonate). While PPIs overall are very safe, several recent studies have raised safety concerns over their long-term use. The following is a list of possible PPI side effects that have recently raised concerns with my patients:

Clostridium difficile infection (C diff). There is a concern that decreasing gastric acid increases the risk of GI infections such as C diff. Multiple studies have indeed shown a 1.4-2.8X increased risk of C diff in patients treated with PPIs, even in patients who have not received antibiotics. The risk seems to be greater than in patients taking H2 blockers such as Zantac. C diff should definitely be considered in patients taking PPIs who develop persistent diarrhea.

Pneumonia. It is possible that decreasing gastric acid may permit bacteria to grow in the stomach, thereby increasing the risk of pneumonia. In fact, there does appear to be an association between PPI use and both community-acquired pneumonia and hospital-acquired pneumonia. This does not necessarily mean that PPI use causes pneumonia, since patients prescribed proton pump inhibitors may be more likely to have other health problems that predispose them to pneumonia.

Hypomagnesemia. PPIs cause decreased absorption of magnesium, especially in patients on therapy for more than one year. The FDA suggests checking a magnesium level prior to starting PPIs in patients expected to be on therapy for a long time, and periodically thereafter. This is especially important in patients taking other medications such as diuretics, which can lower magnesium levels as well. Low magnesium levels can usually be corrected by high dose oral supplementation.

Bone fractures. Insoluble calcium, such as calcium carbonate, requires an acid environment in the stomach for optimal absorption. Long-term use of PPIs, which decrease gastric acid, may decrease calcium absorption thereby decreasing bone density and increasing the risk of fractures. The relative risk is 1.30. This mostly occurs in people over the age of 50, current and former smokers, and those taking a large dose of PPIs for an extended period of time. These patients should consider increasing their dietary calcium and taking a calcium supplement that does not require acid for absorption, such as calcium citrate.

Decreased vitamin B12 absorption. Patients who are on long-term PPIs should have their vitamin B12 levels checked annually.

Decreased iron absorption. This is not usually clinically significant, and there are no formal recommendations to check iron levels.

Kidney disease. Long-term PPI use may be associated with chronic kidney disease. This doesn’t necessarily mean there is a causal relationship. Many patients taking proton pump inhibitors are also on NSAIDs which themselves may damage the kidneys. More studies are needed.

Dementia. There have been at least 2 studies showing an association between dementia and long-term PPI use, but it is unknown if this relationship is causal. More studies are needed.

Heart disease. One study estimated that patients taking PPIs were 16-21% more likely to suffer a heart attack than people not taking a PPI. More studies are needed.

Most of the above data is from observational studies, which have limitations because they can only suggest an association, not establish a cause and effect. There is currently a lack of randomized controlled trials on long-term PPI use and their adverse effects. The current recommendation is to use the lowest dose of PPI needed, for the shortest duration of time, and to taper off the medication after being free of symptoms for at least three months. Certainly there are situations where a patient needs to be on a long-term proton pump inhibitors, such as Barrett’s esophagus, esophageal strictures, and gastroprotection from NSAIDs. If you are currently taking a long-term PPI for acid reflux or any other issues discussed, I strongly suggest that you follow up with your physician at Granite Peaks Gastroenterology to discuss the benefits and various risks.

Ulcers Caused by Anti-Inflammatory Medications

Posted on June 10, 2015December 27, 2024 by fuelmarketing

[Updated 2.24.2022]

The two most common causes of stomach and duodenal ulcers are a bacteria called Helicobacter pylori (H pylori) and the use of nonsteroidal anti-inflammatory medications (NSAIDs), which include aspirin. Let’s look at the use of NSAIDs and how to protect your stomach from their harmful effects.

NSAIDs are medications used to relieve pain and reduce inflammation. More than 17 million Americans use various NSAIDs on a daily basis.
NSAIDs include medications such as:
– aspirin (Bayer, Bufferin, Ecotrin)
– ibuprofen (Motrin, Advil)
– naproxen (Aleve, Anaprox, Naprosyn)
– indomethacin (Indocin)
– diclofenac (Voltaren)
– piroxicam (Feldene)
– meloxicam (Mobic)
– celecoxib (Celebrex)
All NSAIDs, including aspirin, may cause ulcers, but there are some important things to know:

The risk of ulcers and their complications varies among the different NSAIDs. The risk is probably highest with indomethacin. Lowest risk may be Ibuprofen, meloxicam and celecoxib.

The risk of ulcers is related to the duration of treatment with NSAIDs. The longer you are on them, the higher the risk. It usually takes a few weeks for ulcers to form after starting an NSAID, but they may occur as early as 7 days.

The dose of the NSAID is also important. Usually, the higher the dose of the NSAID, the higher the risk of causing an ulcer. But even one baby aspirin per day can cause an ulcer for some people.

Other factors that increase the risk of someone developing an ulcer complication while taking an NSAID include:

– a prior history of an ulcer- use of blood thinners such as

– Coumadin

– use of anti-platelet medications such as Plavix

– age greater than 60

– use of steroids such as prednisone

– current ulcer symptoms such as indigestion

If you have any of the above risk factors, you should talk to your doctor about protecting your stomach from ulcers before starting long-term therapy with an NSAID. Depending on your condition and what NSAID you are taking, your doctor may suggest a limited course of medication called a proton pump inhibitor (PPI) such as Prilosec, Prevacid or Nexium while you are taking the NSAID.

Your doctor may consider testing you for the bacteria H pylori before beginning NSAIDs and, if positive, treating you for that.

In summary, if you need to take an NSAID long term, use one that is relatively safe (such as ibuprofen) at the lowest dose needed to control your symptoms, for the shortest duration possible. If you have any of the risk factors listed above, talk to your doctor about taking a PPI during the duration of NSAID therapy to decrease your risk of developing an ulcer complication.

Myth or Fact, Stress Causes Ulcers…

Posted on February 25, 2014December 27, 2024 by fuelmarketing

For years, people have believed that stress caused ulcers. While stress does contribute to a number of gastrointestinal issues (i.e., Irritable Bowel Syndrome), it is not the cause of ulcers. There are two main causes of ulcers: (1) Medications, primarily non-steroidal anti-inflammatory drugs (NSAIDs), which includes both over-the-counter and prescription medications such as aspirin, ibuprofen, naproxen and others; and, (2) a chronic bacterial infection known as H. Pylori– which has been identified in 65-85 percent of those found to have stomach and duodenal ulcers. (Excessive alcohol use and smoking exacerbate and may promote the development of ulcers.)

Now that doctors know the two main causes of ulcers- NSAIDs and H. Pylori infection- they are able to detect them, treat them, and cure patients of their ulcer disease. Whereas in the past, a patient might have had to undergo surgery for their ulcer, now doctors can manipulate the medications or treat the H. Pylori with antibiotics. Surgery is a rare option.

H. Pylori is the most common infectious agent in the world and is especially prevalent in under-developed countries. Scientists are not sure how the H. Pylori infection is spread, but suspect it is contracted through food and water.

“There are different strains of H. Pylori,” explains Granite Peaks Gastroenterologist Kyle Barnett, MD. “You may get the bacterial infection when you are young, but it might not cause symptoms for many years. If the strain is non-aggressive, you may never even know you have the infection.” When it does present itself, it is important to treat the infection as it can lead to serious diseases. “When we see stomach cancer, this bacteria is often present,” confirms Dr. Barnett, who has been treating patients for more than 20 years.

Detecting the bacteria can be done through a variety of noninvasive tests. One of the easiest, quickest tests is the breath test method done during an office visit. A blood test identifies antibodies, signaling prior exposure to the bacteria- it doesn’t necessarily mean you are still infected. Like the blood test, a stool test can also show whether the bacteria is present.

Another method of detecting H. Pylori is to do a biopsy. “Generally, we do a biopsy if we’re performing an upper endoscopy on a patient who has exhibited ulcer symptoms,” explains Dr. Barnett. There are factors that can influence the sensitivity of all the tests (i.e., if the patient has been taking acid blockers or antibiotics).

“Providing your doctor with a detailed account of what you are taking and your symptoms will help determine what tests and steps should be taken next,” advises Dr. Barnett. He points out that it is common to see the bacteria in groups who have emigrated together or in families, since they have shared space, food, and similar habits. This means if your siblings or parents have tested positive for H. Pylori, you could carry it too.

While abdominal pain is one of the symptoms of ulcers (see sidebar), it could also be a result of a number of gastrointestinal issues, such as acid reflux, pancreatitis or gall bladder issues. Testing for H. Pylori will help determine if an ulcer may be involved in the patient’s discomfort. Immediate evaluation is necessary when gastrointestinal bleeding is the presenting symptom, such as passing black or bloody stools. When blood mixes with acid in the stomach, it turns black.

The good news about ulcers? They are very treatable. “Twenty years ago we knew very little about the role H. Pylori played in the development of ulcers. Oftentimes, ulcers were a chronic problem in people; they would require surgery, sometimes removing a portion of their stomach as their ulcer treatment,” recalls Dr. Barnett. “Now, it is a rare patient that requires surgery. We can treat them medically.”

If a patient comes in with symptoms of burning abdominal pain, nausea, vomiting, or any symptoms that suggest a more aggressive process, (i.e., bleeding, weight loss, trouble swallowing) or is elderly, they should be evaluated as soon as possible. Recognizing the symptoms and causes of ulcers can lead to earlier detection, specific non-surgical ulcer treatment, and hopefully prevention of complications of ulcers.

Pinpoint the cause of your gastrointestinal symptoms. Schedule an appointment with your Granite Peaks gastroenterology specialist today to begin the healing process.