Proton pump inhibitors (PPIs) are medications which are used commonly to control acid reflux. Some common names are Nexium, Prilosec, and Prevacid. These are highly effective for acid reflux and GERD, but long-term use carries risks including nutrient deficiencies, infections, kidney disease, and fractures. They should be used appropriately, with alternatives considered when possible.
Some medications in this class are available over the counter, which may lead to people thinking they are safe to take whenever they want. In this blog I want to highlight some recommendations and also concerns with long term use.
Appropriate Use of Proton Pump Inhibitors
- Short-term therapy: PPIs are most effective for short courses (typically 2–8 weeks) to heal erosive esophagitis or control frequent heartburn.
- Indications for long-term use: Severe GERD, Barrett’s esophagus, Zollinger-Ellison syndrome, or chronic esophagitis may require indefinite therapy.
- FDA guidance: Over-the-counter PPIs should be limited to 14-day courses, up to three times per year.
- Clinical oversight: Long-term use should be monitored by a gastroenterologist, with periodic reassessment of necessity.
Dangers of Long-Term PPI Use
Research has raised concerns about extended therapy, especially beyond several months:
- Nutrient malabsorption: Reduced stomach acid impairs absorption of calcium, magnesium, iron, and vitamin B12, leading to deficiencies.
- Bone health: Increased risk of osteoporosis-related fractures of the hip, spine, and wrist due to impaired calcium absorption.
- Infections: Higher risk of Clostridium difficile diarrhea and pneumonia, as stomach acid normally protects against pathogens.
- Kidney disease: Observational studies suggest an association with chronic kidney disease and acute interstitial nephritis.
- Dementia and cardiovascular disease: Some studies show possible links, though evidence is inconsistent and not proven causal.
- Rebound acid hypersecretion: Stopping PPIs abruptly can worsen reflux symptoms, making tapering important. Please talk to your doctor before stopping and develop a plan for tapering and discontinuing.
Alternative Treatments for Acid Reflux
For patients who do not require indefinite PPI therapy, alternatives include:
Lifestyle Modifications
- Dietary changes: Avoid trigger foods (spicy, fatty, citrus, caffeine, alcohol).
- Meal timing: Eat smaller meals, avoid lying down within 2–3 hours after eating.
- Weight management: Reducing abdominal pressure can lessen reflux.
- Elevating the head of the bed: Helps prevent nighttime reflux.
Alternative Medications
Alternative medications may have their own side effects, please talk to your doctor before making any changes.
- Antacids (Tums, Rolaids, Mylanta): Provide quick, short-term relief but require frequent dosing.
- H2 blockers (famotidine/Pepcid): Reduce acid secretion, less potent than PPIs but safer for long-term use.
- Alginate-based therapies (e.g., Gaviscon): Form a protective barrier to reduce reflux episodes
Procedural Options
- Endoscopic or surgical interventions: Fundoplication or newer endoscopic techniques may be considered for refractory GERD.
- Magnetic sphincter augmentation (LINX device): Strengthens the lower esophageal sphincter.
⚠️ Potential Side Effects of Long-Term PPI Use
- Nutrient Deficiencies
- Vitamin B12 deficiency: Reduced stomach acid impairs absorption, potentially causing fatigue, nerve problems, or cognitive changes.
- Magnesium deficiency: Can lead to muscle cramps, irregular heartbeat, and weakness.
- Calcium malabsorption: May contribute to osteoporosis and fracture risk.
- Bone Health
- Fractures of the hip, wrist, and spine have been linked to long-term PPI use due to impaired calcium absorption.
- The FDA has issued warnings about fracture risk with extended therapy.
- If you have been on a PPI for a long period of time your health care provider may order a DEXA scan to check your bone density.
- Infections
- Clostridioides difficile (C. diff) infection: Altered gut microbiome increases susceptibility.
- Pneumonia: Reduced stomach acid may allow bacteria to thrive and reach the lungs.
- Kidney Disease
- Chronic kidney disease (CKD): Studies show a 20–50% higher risk among long-term users.
- Acute interstitial nephritis: A rare but serious inflammatory reaction in the kidneys.
- Other Concerns
- Drug interactions: PPIs may affect medications like clopidogrel (Plavix), warfarin, and some seizure/HIV drugs.
- Rebound acid hypersecretion: Stopping PPIs suddenly can worsen reflux symptoms.
- Possible dementia link: Earlier studies suggested an association, but newer evidence does not support a strong connection.
✅ Safe Use Recommendations
- Lowest effective dose, shortest duration: Guidelines recommend minimizing exposure unless medically necessary.
- Indications for long-term use: Severe GERD, Barrett’s esophagus, chronic esophagitis, or prevention of recurrent GI bleeding.
- Regular reassessment: Providers should periodically evaluate whether continued therapy is needed.
References:
- Gerd diet: Foods that help with acid reflux. GERD Diet: Foods That Help with Acid Reflux (Heartburn) | Johns Hopkins Medicine
- Foods to eat and avoid if you have GERD. May 21, 2025 GERD Diet: Foods To Eat and Avoid
- GERD diet, foods to avoid if you have acid reflux. July 31, 2023GERD diet: Foods to avoid to reduce acid reflux – Harvard Health