Heartburn (GERD) Drugs: A New Caution

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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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So does this happen only when you lie down?

It's not clear. Certainly when you lie down you increase the chance of stomach contents refluxing back into the esophagus, and this could make it easier for bacteria to translocate from the stomach to the respiratory tract. If you do have reflux symptoms and you're on acid blocking medication, you should keep the head of your bed elevated at bedtime.

When you have HIV what are the risks for developing pneumonia during heartburn treatment? Is it better to stop the drug to stop the possibility of developing pneumonia, since HIV makes it easier to get pneumonia?

The answer is not known; this study did not address that. I would say that if you have a definite indication or need for acid blocking medicine, that I would take it even if you have HIV, which already predisposes you to high risk of pneumonia. On the other hand, high-risk patients, such as you or those people with emphysema who feel they can safely go off acid blocking medicine, can do so.

I have severe asthma and reflux. I heard that this was a special problem for asthmatics. What am I supposed to do now?

In some studies, up to 80 percent of asthma patients have gastroesophageal reflux. This acid reflux can certainly make their asthma symptoms worse. If an asthma patient is taking acid blocking medication, such as Protonix or Nexium, and it is helping their asthma, then I would not stop it. If, on the other hand, after three to six months of treatment with acid blocking medicine there was no perceived benefit in asthma symptoms, I probably would stop the medicine.

"I think there's a greater danger of people stopping their medication because of fear of pneumonia than the actual extremely small risk of ever getting pneumonia due to an acid blocking drug."

For those who are dealing with GERD and may want to help themselves, what should they do in terms of diet and lifestyle?

In my book, Gastrointestinal Health, I outline extensive non-drug treatments for gastroesophageal reflux. Certain dietary restrictions, such as:
  • Avoiding greasy foods
  • Avoiding peppermint
  • Avoiding chocolate
  • Avoiding nuts
  • Avoiding caffeine-containing beverages
  • Elevating the head of the bed
  • Not eating for at least three hours before lying down

What do you do if you think you might be getting sick? How different is pneumonia from the flu, as far as symptoms go? Should patients on heartburn meds call the doctor at the first sign of feeling sick?

Basically symptoms of pneumonia include fever and cough productive of puss sputum. You may also have shortness of breath. Certainly, if you develop those symptoms, whether or not you're on acid blocking medication, you need to see your doctor. People will develop common cold symptoms several times a year. This has nothing to do with acid blocking medicine.

What are the drug companies saying in response to this?

I don't know what the drug companies are going to say, but if I were working for a drug company I certainly would feel comfortable trying to ease the general population's worry about developing pneumonia while on acid blocking medication.

I think there's a greater danger of people stopping their medication because of fear of pneumonia than the actual extremely small risk of ever getting pneumonia due to an acid blocking drug. I do not think this study should significantly change the way doctors treat their patients who have acid-related disease.

We do know, however, there are a lot of people who continue to take this type of medication even though they may not actually require it. If that is the case, then doctors should take their patients off any medication that is really not necessary.

Overall, the H2 blockers and proton pump inhibitors, drugs that block acid, remain some of the safest drugs we have. The biggest issue related to this article is how to prevent doctors and patients from overreacting to the article.

Our thanks to Steven Peikin, MD, for joining us. For more information on all kinds of gastro-related health issues, read Gastrointestinal Health, a book by our guest, Steven R. Peikin, MD. And be sure to visit the WebMD message boards to ask questions of our online health professionals and to share questions, comments, and support with other WebMD members.

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Reviewed on 11/23/2004 12:12:21 AM

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