In graduate school, we had to do a research project. These kinds of research projects are the case with any graduate program. In our research section, we had a group of four very annoying women that called themselves the “PPI girls.” The group was led by one person who was very annoying and seemed to be on a mission about the overuse of PPIs.
She wasn’t half wrong, PPIs or proton pump inhibitors tend to be a very overused medication. It seems like that for any reason, we immediately put someone on a proton pump inhibitor as a provider. Well, in the short run, this can be a good thing, meaning about two weeks to a month; in the long term, it’s not. The reason being is that we are trying to treat something with medication that in many cases, can be rectified by lifestyle changes.
Oh no, Nursie poo said, “lifestyle changes,” let’s run screaming into the hills because we don’t want to take the hard road out of the situation. I get it; I’m the same damn way, I want to run to my primary care provider and say give me a pill for this problem instead of taking five minutes to fix it. We are a convenience society, and as I’ve said before in the blog, the “Nintendo generation,” if we can’ do it in 3 to 5 minutes, we’re bored and move on. It’s become an age of convenience and when we think of medicine, we often think of oh I’ll get a pill and I will fix it. I’ve taken PPIs off and on for about ten years related to a hiatal hernia, which is a physical condition. A hiatal hernia is pretty much where the stomach bulges through the opening of the diaphragm that your esophagus comes through. It causes some difficulty swallowing and in severe circumstances. It can require surgical correction.
In most cases, it can be treated episodically by PPIs and so it is, but no treatment for this is foolproof. Often when I take PPIs, I have all kinds of issues below that in terms of the fun things that we get from medications, like diarrhea. I know the medication bottle makes it sound so lovely, “loose or runny stools.” More like, “Is that gas?” No, it wasn’t and can you bring me a new pair of pants. Gross, I know, but that is what happens with long-term PPI use.
One of the major things it has been studied and proven through research is that long-term use of PPIs can lead to infections such as C. difficile. C. diff is a very nasty lower intestinal bacteria that makes you projectile poo. It also makes you sick. Lots of stomach cramping and you are also very contagious, which means being careful about who’s around you and careful handwashing and things like that. So really a long-term use of them can lead to some pretty bad things.
On Tuesday, the VA announced that it was going to be scaling back on the prescription of PPIs. The study published on their blog found here. Although there’s nothing to read as most of the meat of this is written right here below.
A national VA program called RaPPID is underway to do the same on a wide scale and to teach best practices. The acronym stands for the National Randomized Proton Pump Inhibitor De-prescribing program.
The research team is led by Dr. Sameer Saini of the VA Ann Arbor Healthcare System in Michigan, Dr. Loren Laine of the VA Connecticut Healthcare System, and Dr. Yu-Xiao Yang of the Corporal Michael J. Crescenz VA Medical Center in Philadelphia.
VA researchers are evaluating the program’s effectiveness. They are working with VA National Pharmacy Benefits Management Services, which is leading RaPPID. The researchers are trying to understand how effective RaPPID has been in improving the use of PPIs and ensuring no negative health consequences, such as peptic ulcer bleeding, have occurred with PPI de-prescribing.
The VA is also trying to reduce costs as well as the impact on health. One thing I will say is no matter how good a particular health care system is, 90% of what they do is not patient-focused its cost-focused. They are a business, every insurance company and HMO is a business. There is very little altruism left especially at a corporate level. That is not to say that the VA does not care about their patients. However, they still have a bottom line that they have to meet and in this case, that’s about $50 million in savings, which is not necessarily chump change.
It’s not necessarily a bad thing to discontinue PPI. You need to talk to your provider and follow the advice that your primary care provider has for you regarding a PPI. Sometimes they are necessary but we go back to 2 to 4 weeks. A few years ago Prilosec became an over-the-counter and you could buy two weeks’ worth of it. The reason you can only buy two weeks’ worth of it is is that’s the max recommendation for Prilosec as a daily drug. The thing that a lot of people didn’t read on the box were our two favorite words, “lifestyle changes” or “lifestyle modifications.”
I’m not just bitching at all y’all; I am looking at myself in the mirror while I do this. Oh, that’s right; I can’t see myself in the mirror… Oops. Here’s how you make these lifestyle changes. It’s so bloody simple that a caveman could do it. Oh God, I am like the queen of metaphors today. It does require a smidge of work; however it can be well worth your time especially if you like to avoid taking another pill. So the trick here is to keep a food diary and that means everything that goes into your mouth for 4 to 7 days preferably seven. Also, in this food diary, you need to document if you have any changes in gas, stomach upset, belching, farting, and heartburn (even strange desire to tap dance too…). Then after the seven days, you go back and you look at the meals that you ate that cause these changes and look for patterns. So, if you have a pain every time you eat pasta, then you know that maybe that’s a food you need to be careful or if you can cut it out of your diet (I don’t think I could cut pasta out of my diet). If that is a staple food for you, you may need to look for an alternative to this food or alternative preparations that allow less stomach upset. Or, you realize that every time you have pasta or red sauce on the pasta, you’re going to have heartburn and gas.
There are also episodic gas remedies such as H2 blockers that also work on stomach acid, and unlike PPIs there episodic as well. So taking an H2 blocker, such as ranitidine, can have an immediate effect and only have to be taken after you eat pasta. H2 blockers are also not a long-term medication and do not, at least at this point, show any signs of long-term ill effects. While I know you would rather eat something and take a pill, changing a habit is the long term solution.
Make no mistake; there are people that need to be on long-term PPI regimens. Those patients are not the people that are affected by these kinds of decisions like the one the VA made. What this is talking about is the just random handing out of PPIs like candy to patients who are “getting a lot of heartburn.” The funny part is in the introduction of PPIs; you pretty much had to have an endoscopy the show that they needed or should be continued, because of erosion or whatever else. Now? Not so much.
So once again, I’m the bearer of bad news and tell you that probably lifestyle modifications are, once again going to provide the best outcome as opposed to medication. It’s funny to think that I spent three years struggling through grad school to spend more time saying, “Hey, you gotta change what you’re doing.” While this isn’t always the case, nine times out of 10, it is. It’s sad to think that I’m in my early 50s and I’m just really starting to have that concept gel for me. Oh well, live long and learn.
Remember to be the kind of person that your dog and your mom hope you are.