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Monday, May 17, 2010

Managing Your Upset Stomach

Proton pump inhibitors are a very popular form of antacid medication usually abbreviated PPIs. They're available in both prescription and over the counter (OTC) strengths, and the latest issue of Archives of Internal Medicine states their prescription-only sales total almost $14 billion per year. Only the manufacturers know what the OTC sales are worth, but what's emerging in this issue of Archives is a rather concerning picture of the multitude of side effects related to use of PPIs.

Turns out that women in the Women's Health Study who took PPIs had an increased risk of fractures of the spine and lower arm. Patients who took PPIs and were hospitalized had a much heightened risk of becoming infected with that increasingly frightening pathogen, Clostridium difficile. C. difficile, for those in the know, causes diarrhea, often bloody, and can be very challenging to eradicate. And those on PPIs are also more likely to develop both hospital- and community-acquired pneumonia. Yikes! How then can we account for the popularity of PPIs?

Many people are placed on PPIs (and probably shouldn't be) when they're hospitalized and when they're discharged they simply stay on the medication. About a quarter of US adults report dyspepsia, medicalese for upset stomach or indigestion, and these drugs are very effective at treating it. Physicians accustomed to providing relief may prescribe PPIs. But the author of an editorial states that between 53 and 69% of prescriptions for PPIs are NOT indicated.

So, hmmmm. Seems we have a very effective medication for a common complaint that's costing our healthcare system a lot of money and that looked to be innocuous but now isn't. Clearly, PPI use needs to be scrutinized very carefully. What are the alternatives?

First of all, prevention, as always, is worth a pound of PPIs. Don't eat large meals late at night and then go to bed. Curtail consumption of wine, coffee and perhaps chocolate before retiring. Sleep with your head elevated. Lose weight if you need to.

So you overeat and go to bed. Then what? Start with the little guns first. Garden variety calcium-based antacids can be very effective, and then perhaps reach for the class of antacids known as H2 blockers, which although still associated with side effects don't seem to be quite as deleterious as PPIs.

Other topics in this week's podcast include the benefits of consuming nuts in Archives, the real incidence of food allergies in JAMA, and the effect of fibrates on cardiovascular risk in this week's Lancet. Until next week, y'all live well.

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