I have a confession to make: something has gone seriously wrong with the way GPs prescribe heartburn medication.
The drugs in question are called proton pump inhibitors, or PPIs, and they are among the most widely used medicines worldwide.
That is understandable when more than six million people in Britain are affected by heartburn, also known as acid reflux.
The condition occurs when stomach acid travels up into the throat, causing nausea, discomfort and chest pain. For many patients, the symptoms can be miserable—especially when they interrupt sleep.
PPIs, including omeprazole, lansoprazole and esomeprazole, are remarkably effective. They can ease or eliminate acid reflux symptoms within just a few hours.
Doctors also prescribe them to people taking anti-inflammatory medicines over long periods, as PPIs can help protect against potentially dangerous stomach bleeding.
Even so, I now advise my patients to stop taking these drugs as soon as it is safely possible.
The reason is that PPIs were not intended for routine long-term use. Yet research suggests that 40 per cent of patients take them for at least 12 months, while one in 10 remains on them for five years or longer.
Around one in five Britons suffers from acid reflux, which occurs when stomach acid leaks into the oesophagus and throat, causing a burning sensation and chest pain
That is deeply concerning because studies have linked excessive or prolonged use with a higher risk of bone fractures, vitamin deficiencies and potentially even dementia.
When I raise this with patients, many worry that stopping their tablets will cause their heartburn to return worse than ever. There is some truth to that fear: suddenly coming off PPIs can trigger problems.
However, a number of practical lifestyle changes can help people reduce their reliance on these medicines and eventually come off PPIs.
Those taking PPIs alongside anti-inflammatory drugs may also be able to stop, provided they take the right precautions and receive appropriate medical advice.
So, what changes can make a difference?
First, it helps to understand what causes heartburn. At the bottom of the food pipe—the oesophagus—is a ring of muscle that normally prevents stomach contents from flowing backwards. If it fails to close properly, acid can rise from the stomach into the gullet.
This is what causes that burning sensation behind the breastbone, along with a sour taste in the mouth, and it’s why symptoms are often worse after eating, lying down or bending over.
Around ten million people regularly take omeprazole – or similar drugs such as lansoprazole – costing the NHS about £300million a year
Over time, heartburn can also inflame the lining of the oesophagus, which can raise the risk of oesophageal cancer.
PPIs work by switching off the tiny pumps in the stomach lining that produce acid, cutting down how much is made in the first place. This eases symptoms and gives the lining of the oesophagus a chance to heal.
Used in short bursts, these drugs can be miraculous – ending the suffering of heartburn patients.
However, over the years, researchers have realised that we do, in fact, need stomach acid and limiting its production for too long can have serious consequences.
We now know that patients taking PPIs are more likely to suffer nutrient deficiencies including vitamin B12, magnesium and iron, all of which can lead to fatigue and weakness.
They are at a greater risk of developing chronic kidney disease, an irreversible and potentially deadly disease.
PPIs users are also more likely to suffer bone fractures, certain infections and, on rare occasions, gastric cancer.
There is even some evidence that PPIs patients have an increased chance of developing dementia – though more research is needed to prove this link.
However, all told, for many patients the reasons for coming off PPIs far outweigh those for staying on them – not least because there are a series of lifestyle changes that can make them obsolete.
Losing weight, if you carry excess weight, has the strongest evidence base of any lifestyle intervention.
Extra weight increases pressure in the abdomen and worsens reflux, and even a modest loss of five to ten per cent of your body weight can significantly improve symptoms.
It’s also worth paying attention to triggers. Large meals, eating close to bedtime, alcohol, caffeine, chocolate, fatty or spicy food and fizzy drinks can all provoke reflux, so cutting back on these can make a real difference.
Stopping smoking and cutting back on alcohol more generally will help too, as will something as simple as raising the head of the bed.
If symptoms tend to be worse at night, tilting the bed so your head and chest are higher can stop acid travelling back up while you sleep.
It is important that patients do not come off the tablets suddenly, as this can make symptoms worse. Instead, patients should come off them gradually with the help of their GP.
But for heartburn patients, these changes could be enough to get them off PPIs.
However, not all PPIs patients are taking them for heartburn. There are those on anti-inflammatory painkillers, such as ibuprofen or naproxen, for chronic pain conditions, who also need them.
These drugs can irritate the stomach lining and trigger dangerous bleeds – and PPIs can stop this from happening.
In fact, some studies suggest that the majority of patients who take PPIs for a year or more are taking them alongside anti-inflammatories. So what can these patients do to kick their PPIs?
The first step patients can take is to talk to their GP to find out whether their dose of anti-inflammatories can be lowered or whether it can be taken only as needed rather than every single day. Using them less could eliminate the need for PPIs.
It’s also worth asking about alternatives.
Paracetamol, for example, is a painkiller that does not carry the risk of stomach bleeds. There are anti-inflammatory creams that are instead applied to the skin, which are particularly helpful for joint pain.
There are also ways of managing pain that don’t rely on painkillers, including physiotherapy – regular exercises and stretches proven to ease suffering.
However, the truth is that not everyone can stop taking anti-inflammatories and it is important that these patients keep taking PPIs.
Stomach bleeds can be dangerous – even life-threatening – so, in this situation, the benefits of a long-term course of PPIs outweigh the risks.
But for everyone else, my advice would be to get off them as soon as is safely possible.
Heartburn can often feel never-ending but, with the help of your GP, something as simple as eating earlier meals or cutting out alcohol could allow patients to kick PPI tablets.
