Heartburn Drugs: A New Caution

WebMD Live Events Transcript

A recent study revealed that the use of gastric-acid suppressive drugs is linked to an increased risk of pneumonia. What is the connection, and what are experts advising in the wake of this news? Are you at risk? Gastroenterologist Steven Peikin, MD, joined us on October 28, 2004, to explain the new study and answer your questions.

The opinions expressed herein are the guests' alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

Welcome to WebMD Live, Dr. Peikin. Thank you for joining us today. Please give us a lay audience explanation of what the study in this week's JAMA means.

The study that was published in this week's JAMA indicated that drugs that we commonly use to treat heartburn, peptic ulcers, and other digestive complaints, are associated with an increased risk for the development of pneumonia. Although at first glance this may seem alarming, in actuality, it is not alarming at all. The actual risk to a person taking acid blocking medicine of developing pneumonia is one patient in 100,000 patient years of exposure. In other words, if you have a bunch of people taking drugs like Zantac or Nexium and the number of combined years of exposure exceeds 100,000, then you will see one case of pneumonia. Obviously, the risk is very small.

The risk seems to be slightly greater in those people taking higher doses of so-called proton pump inhibitors, such as Nexium, Protonix, Aciphex, and Prilosec, than the H2 blockers, like Pepcid, Zantac, or Tagamet. In fact Pepcid and Tagamet users did not show a significant risk.

Almost all drugs are associated with certain side effects. Although it appears that a rare complication of acid inhibiting therapy may be pneumonia, pneumonia is certainly very treatable. Furthermore, if somebody were to stop their medication because they feared getting pneumonia, they would possibly be at risk of developing complications of acid peptic disease, such as gastrointestinal bleeding or worsening heartburn.

Obviously, if the person doesn't need to be on one of those drugs they should stop it, but I am not recommending to my patients who need H2 blockers and proton pump inhibitors to stop their medication because of this potential rare complication of pneumonia.

Are all patients equally at risk, or are older people or those who take a lot of heartburn meds more at risk, for example?

In this study, people who were at higher risks of developing pneumonia were those with emphysema, congestive heart failure, and other heart and lung diseases. These people are known to be at higher risk anyway of developing pneumonia.

The drugs that showed the highest risk of developing pneumonia were double doses of the proton pump inhibitors, like Nexium. That being said, the risk was still extremely small.

"I am not recommending to my patients who need H2 blockers and proton pump inhibitors to stop their medication because of this potential rare complication of pneumonia."

There are a lot of heartburn treatments out there. Does this study warn about just a certain kind?

All heartburn treatments that work by inhibiting acid or neutralizing acid may potentially increase the risk of pneumonia. The stronger the acid-suppressing drug, the higher the risk. So drugs like Nexium, especially if they're given more than once a day, or any of the other proton pump inhibitors, such as Protonix, Aciphex, Prevacid, or Prilosec, would be expected to be higher risk than H2 blocker drugs, such as Zantac. In fact, there was no definite risk associated with some of the H2 blockers, such as Pepcid or Tagamet.

The risk of developing pneumonia during treatment for heartburn still remains extremely small. When you take a drug, you and your doctor always need to weigh the risks of the drug against its potential benefits. For most heartburn sufferers, and for most people who are trying to prevent complications of arthritis medicine by taking drugs that inhibit acid, the risks of stopping the drug are probably greater than the small risk of developing pneumonia. I believe that people should not overreact to this article.

Do Tums have any ingredients that can be a conduit for pneumonia?

Although this study did not study antacids to any extent, it certainly is possible that antacids could also carry with them a risk of developing pneumonia. In 1987, a study was published in the New England Journal of Medicine showing that ICU patients who received antacids to prevent stress ulcers had a higher risk of developing pneumonia. Again, the risk appears to be extremely small.

How do these drugs increase the risk for pneumonia?

The mechanism appears to be that the suppression of acid in the stomach allows bacteria that are not normally in the stomach to grow. Acid prevents the growth of bacteria. If you block the acid it is possible for bacteria to grow in the stomach. If you lie down at night, you may reflux stomach contents back up into your esophagus, and with it some bacteria, which can then find their way into the respiratory tract in the back of the throat.

One potential criticism of the study was that most of the people who take these drugs take them for heartburn caused by stomach contents refluxing back into the esophagus. It could be that gastroesophageal reflux itself causes aspiration-induced pneumonia. The people who require the highest doses of acid inhibiting medicines for their reflux are those who have the worst reflux, and therefore may be more prone to develop pneumonia.

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