Physicians can prescribe longer PPI use

DEAR DR. ROACH: What’s the story with Prilosec? Doctors routinely tell people with GERD or acid stomach to take this forever. Yet it clearly describes only a 14-day treatment on the box. A physician assistant told me that because of a rare infrequent condition some users have that the manufacturer is legally bound to post the 14-day limit, but that the general population can safely ignore it. Can you enlighten and reassure those of us whose physicians have said to take it long term? — C.D.C.

ANSWER: The patient instructions in the over-the-counter versions of proton pump inhibitors, such as omeprazole (Prilosec), do recommend a 14-day course. However, longer courses may indeed be prescribed by a licensed prescriber, such as a PA. Even so, there are relatively few people who need lifelong medication. Those who do may have a condition such as Barrett’s esophagus, in which PPIs — the most potent medical treatment to suppress stomach acid — are necessary. They not only relieve symptoms, they are also prescribed in hopes of reducing the risk of developing cancer of the esophagus. The data on this are still not clear.

For people with acid reflux (also called gastroesophageal reflux disease), PPIs are usually not needed lifelong. However, it may still be reasonable to use these drugs long term if the prescriber feels the benefit outweighs the risk.

There are several risks of long-term use of PPIs. Stomach acids are important in protecting against bacteria, and two kinds of bacterial infections are more common in PPI users. The first is in the colon, especially of Clostridium difficile, where PPI users are about 30% more likely to be infected and may do so even without the antibiotic use that is the most common risk factor for C. diff. The second is pneumonia, although the apparent association may not be as strong as formerly thought.

Low stomach acid may decrease absorption of vitamins and minerals, especially magnesium, iron and vitamin B12.

PPIs were thought to increase the risk of a rare tumor, gastric carcinoid, based on data from rats, and of colon cancer. Those risks have not been seen in humans. Early data suggest increased risk of kidney disease and dementia. That risk appears to be small, if it even exists.

Long-term PPI use has some risk of side effects and should be used only when there are benefits to PPIs that can’t be obtained with other treatments, including other medications and lifestyle changes. This especially includes better diet, weight loss when appropriate and not eating right before bed.

DEAR DR. ROACH: Your recent column on antibiotic resistance prompts me to ask about something that has bothered me for some time. Many cleaning products are labelled “kills 99.9% of bacteria.” What becomes of the other 0.1%? It seems logical that the remaining bacteria are more resistant than the killed ones and could reproduce and/or mutate to produce even more virulent strains. — M.G.H.

ANSWER: Bacteria do have ways of becoming resistant to treatments meant to kill them, such as antibiotics and antimicrobial soaps. However, strong detergents and bleaches have so many ways of killing bacteria that the bacteria cannot become resistant to these. The percent of bacteria killed has more to do with the time spent in contact with the cleaner (and perhaps some legal protection for the manufacturers). It is very hard to kill 100% of bacteria. They can hide in tiny crevices of materials. Sterilizing (killing 100%) requires high heat, pressure or prolonged contact with potent agents. Some bacterial spores, such as Clostridium difficile, are very hard to kill even with effective cleansers.