The consequences of over prescribed heartburn meds

Proton pump inhibitors, such as Nexium, are among the most widely prescribed medications in the United States with nearly 120 million prescriptions filled in 2009 at a cost of $13.6 billion, according to IMS Health, a company with offices in Plymouth Meeting, Pa. that tracks drug sales.

These drugs are widely used to treat heartburn, although they are intended for more serious and chronic conditions such as bleeding ulcers. In Tuesday’s edition of the Archives of Internal Medicine, five studies (1, 2, 3, 4, and 5) and an editorial examine the adverse consequences of the drugs, including a slight increase risk of fractures for women after menopause and an increased risk of a serious bacterial infection.

The latest studies follow a report two-weeks earlier in the same medical journal that found proton pump inhibitors increase the risk of rehospitalization for patients on the bloodthinner Plavix.

In the editorial, Mitchell H. Katz of the San Francisco Department of Public Health wrote that the drugs are overprescribed and used inappropriately for conditions such as heartburn that are unwarranted. Part of the problem, he says, is that our medical system tends to be overzealous in prescribing a drug for common problems such as indigestion. Katz’s editorial concluded:

The patient has a symptom; we give it a fancy name. We call persistent indigestion (without evidence of ulcer disease or esophagitis) "functional dyspepsia." We call heartburn "gastroesophageal reflux." Next, we treat the symptom with a medication, ideally one in pill form.

The problem with this paradigm is that for most patients, the adverse effects of PPIs [proton pump inhibitors] outweigh the benefits. Reducing the unnecessary use of these medications will require action by both physicians and patients. As physicians, we should offer treatments other than PPIs for functional dyspepsia, prescribe short courses of PPI treatment (after disclosure of possible risks and benefits), and consider a trial of discontinuing PPI therapy in patients who are asymptomatic. Once our patients fully appreciate the adverse effects of PPIs, they themselves may prefer other treatments, including a tincture of time (many cases of dyspepsia resolve on their own), behavioral changes (e.g. eating smaller meals [especially before bed], weight loss, smoking cessation, stress reduction), and other nonmedical interventions (e.g. raising the head of their bed).