Treating GERD - Do the benefits outweigh the risks?

What should you do when the media reports that a drug you’ve been on for years and you may never be able to quit has just been linked with some potentially dire consequences? Consequences such as a higher risk of heart attack, stroke, dementia, or (yikes!) even cancer. This is not an idle question.  For example, two small studies have suggested that long-term use of two very commonly-prescribed medications, omeprazole (Prilosec/Losec) and esomeprazole, (Nexium), which are used to treat gastro-esophageal reflux disease (GERD), may lead to a higher risk of heart attack and heart failure. This news spooked me since I’ve been on Nexium for years and no matter what I do, I can’t get off it.

Why can’t I get off Nexium? Because I love to eat. You see in GERD, digestive acid refluxes back into the esophagus from the stomach, leading to those symptoms so many of are familiar with: heartburn, regurgitation, as well as discomfort or pain. GERD can also produce recurrent hoarseness, throat clearing, coughing, even wheezing when refluxed acid irritates the throat and airways, a problem that is often worse at night. 

Now, if that were all that GERD led to most of us would easily put up with the nuisance symptoms and occasional sleepless nights. Trouble is GERD is much more than a nuisance. It can also lead to respiratory infections such as pneumonia from swallowed acid, and sinus infections. More seriously, since the cells in the esophagus are not protected against acid (as stomach cells are), untreated GERD can "burn" the esophagus leading to ulcers and scarring that eventually narrow the esophagus (a stricture), making swallowing increasingly difficult.

The really big worry, though, is that patients with GERD have a significantly higher rate of a pre-malignant change called Barrett’s esophagus. And a small but substantial number of people with Barrett’s esophagus go on to develop cancer of the esophagus, a malignancy that is increasing in prevalence and which continues to carry a poor prognosis. Preventing these complications is the main reason why it’s so important to control GERD.

I do all those lifestyle things that experts who don’t have GERD assure me will improve my condition— but never do: I’m not overweight, I don’t wear tight clothing, I don’t eat heavy, fat-laden meals (I try to, but my wife won’t let me), I avoid foods that provoke my symptoms (bananas, would you believe, but not, thank god, coffee). I don’t drink too much alcohol ("too much" is anything beyond what I want to drink that night). I don’t lie down for several hours after eating, and the head of my bed is so elevated that one of these nights one of us is going to slip off the edge. But none of these things help much. Antacids don’t help either; unless I take so many that my kidneys are in danger of being overwhelmed by all the calcium and magnesium.

So even though I hate taking pills, I’ve been on Nexium for years, and my life is miserable when I try to come off it. Nexium is a proton pump inhibitor (PPI), a drug that stops acid production. But when you try to come off a PPI after long-term use, there’s a rebound effect  - you suddenly produce more acid than you would normally, and your stomach and esophagus cells rebel at this onslaught. I’ve tried to come off Nexium several times, but I just haven’t been able to "stomach" the symptoms.

So you can imagine my consternation when news came out recently that the Federal Food and Drug Administration (FDA) in the United States was sitting on two studies that concluded that Nexium might be linked to higher risks of heart attacks and heart failure. Although these stories were quickly followed by an announcement that the FDA didn’t think there was a credible connection (although the FDA is studying these reports and will issue a follow-up bulletin in a few months), I was still an unhappy camper, as were many of you, judging from the emails I got.

So what to do with such news? Well, if you just have mild reflux or "indigestion" and you can deal with the symptoms in another manner, that’s certainly the route you ought to go, even if Nexium gets an all-clear eventually. After all, why use a hammer when you can use a soft mallet?

For me, however, as for so many of you, the only solution is to keep doing as you’ve been doing. First, you should never make a change in what you’re doing based only on media reports, but always discuss your situation with your doctor first. True, your doctor often doesn’t know what to do with such information either, but hey, two heads are better than one.

More important, all drugs carry some risks, risks that must always be balanced against the benefits those drugs are meant to convey. In the case of GERD, as I can testify, the symptoms can make it impossible to enjoy life. As well, the complications of GERD are quite fearsome. Since nothing else works well for persistent cases of GERD, there really isn’t much choice but to continue taking your drugs (unless you want to go on to have GERD surgery, which carries its own set of risks).

But hey, make sure to be awake when that FDA update comes out.

If you have a comment or question for Dr. Hister contact him at ahister@knowitallhealth.com

Reviewed August 25th, 2007