Proton Pump Inhibitor drugs (PPIs) greatly reduce the production of acid in the stomach. They revolutionized and improved the treatment of ulcers in the stomach and duodenum. When I started medical practice in 1981, I saw many patients who had required stomach surgery to treat their ulcers. Remember the good ol’ Billroth procedures? Of course you don’t. The first PPI approved for use in the US. was cimetidine (Tagamet) in 1979.
But wait, you say. “Isn’t there a reason we have stomach acid in the first place?” Good question! Because if we reduce stomach acid, it may cause problems. Regardless of what acid contributes to food digestion, it also kills germs in food and water. Germs that may kill us if ignored. Most of us in the developed world would be horrified to drink untreated water out of a lake, stream, river, or spring. But what do you think Homo sapiens did for most our 200,000 years of our existence?
Omeprazole was made over the counter in 2003 but I don’t think these drugs should ever have been made available without prescription. PPIs are powerful drugs that treat heartburn by reducing gastric acid production. This is accomplished by PPI binding to the hydrogen/potassium ATPase enzyme on gastric parietal cells lining the stomach. PPIs do more than block acid. They are associated with an increased risk of congestive heart failure, kidney disease, long bone fractures, and dementia, vitamin B12 deficiency, reviewed here. Regular use of proton pump inhibitors is associated with increased incidence of type two diabetes, about 24% higher compared to non-users of the drug. Proton pump inhibitors are also linked an with increased risk of small intestinal bacterial overgrowth (which is a clue as to why these drugs can be harmful). They also increase the risk of infection by Clostridiales difficile by about 2x.
Most of these individual observational studies are unable to establish causation, but the preponderance of evidence points to PPIs causing harm.
Dr Alcock also found evidence that PPI users who catch COVID-19 have 1.6x increased risk for severe disease and death.
If you’re prescribed a PPI for chronic use, check with your physician to see if you still need it. Occasional use for heartburn shouldn’t be a problem. For chronic heartburn, consider a low-carb diet and stop nocturnal alcohol consumption.
Steve Parker, M.D.
Advanced Mediterranean Diet 
Enlightening post. While I totally agree with everything stated, it deeply troubles me that no effective alternative approach is given beyond eating low carb.
I have been low carb since 2006. It has tremendously improved – but not eliminated – the chronic GERD, reflux & heartburn. It is a daily battle.
My dad was on Tagamet for years. 18 months ago he was diagnosed with colon cancer. The tumor was a significant size. 11 inches of his intestine were removed, followed by aggressive chemo – all this for a man who is in his 80’s.
His oncologist asked him if he had ever taken Tagamet. The association was clear and incriminating.
For myself, getting completely off the offending PPI would not be an option for one reason – what can effectively replace it?
Enzymes, probiotics, papain, low carb eating, etc., all have their place. They are wonderful at what they do.
However – they have not been the silver bullet needed to get my gut fully functional again. Unfortunately, it seems this is a concern that is shared by others, as well.
Would love to know your thoughts on this. Your insights are always on point in your posts.
Thank you for all you do.
Hi, McDonna.
To answer your question, I’ll assume that occasional use of antacids, H2 blockers (histamine 2 receptor agonists like famotidine), and proton pump inhibitors is not an adequate remedy. At some point (sooner rather than later), you’ll also want to be sure the diagnosis truly is GERD and not something else. This may well require a consultation with a gastroenterologist.
Some lifestyle options may help some but not others, and experimentation may be in order.
Lose excess weight. Even common overweight can aggravate the condition.
Elevate head of bed on 6-8 inch bricks.
Avoid supine posture after meals.
No eating for 2-3 hours prior to bedtime.
Avoid tobacco and alcohol.
Avoid tight-fitting garments over the abdomen.
Avoid common triggers: spicy food, carbonated beverages, onions (esp raw), chocolate, high-fat foods, caffeine. If you’re sure these don’t trigger your own GERD, then no particular need to avoid. A spicy meal one week ago doesn’t cause your GERD today. Your triggers will typically be ingested within 30 minutes to 8 hours prior to symptom onset.
Other medication options are….
Sucralfate if pregnant
Metoclopramide is gastroparesis is present (delayed gastric emptying)
Sodium alginate
Bothersome symptoms that are refractory to all usual treatment?
Get EGD (esophagogastroduodenoscopy) and ambulatory esophageal pH-metry from a gastroenterologist.
Final options for refractory GERD:
Anti-reflux surgery
Transoral incisionless fundoplication
There are probably other options for GERD suppression that I haven’t mentioned.