From today’s New York Times, more short sightedness about the unwise use and overuse of drugs in primary care.
As many as four in 10 Americans have symptoms of gastroesophageal reflux disease, or GERD, and many depend on P.P.I.’s like Prilosec, Prevacid and Nexium to reduce stomach acid. These are the third highest-selling class of drugs in the United States, after antipsychotics and statins, with more than 100 million prescriptions and $13.9 billion in sales in 2010, in addition to over-the-counter sales.
But in recent years, the Food and Drug Administration has issued numerous warnings about P.P.I.’s, saying long-term use and high doses have been associated with an increased risk of bone fractures and infection with a bacterium called Clostridium difficile that can be especially dangerous to elderly patients. In a recent paper, experts recommended that older adults use the drugs only “for the shortest duration possible.”
Studies have shown long-term P.P.I. use may reduce the absorption of important nutrients, vitamins and minerals, including magnesium, calcium and vitamin B12, and might reduce the effectiveness of other medications…Other research has found that people taking P.P.I.’s are at increased risk of developing pneumonia; one study even linked use of the drug to weight gain.
But while using the drugs for short periods may not be problematic, they tend to breed dependency, experts say, leading patients to take them for far longer than the recommended 8 to 12 weeks; some stay on them for life. Many hospitals have been starting patients on P.P.I.’s as a matter of routine, to prevent stress ulcers, then discharging them with instructions to continue the medication at home. Dr. Charlie Baum, head of U.S. Medical Affairs for Takeda Pharmaceuticals North America Inc., said its P.P.I. Dexilant is safe when used according to the prescribed indication of up to six months for maintenance, though many physicians prescribe it for longer.
“Studies have shown that once you’re on them, it’s hard to stop taking them,” said Dr. Shoshana J. Herzig of Beth Israel Deaconess Medical Center in Boston. “It’s almost like an addiction.”
“When people take P.P.I.’s, they haven’t cured the problem of reflux,” said Dr. Joseph Stubbs, an internist in Albany, Ga., and a former president of the American College of Physicians. “They’ve just controlled the symptoms.”
And P.P.I.’s provide a way for people to avoid making difficult lifestyle changes, like losing weight or cutting out the foods that cause heartburn, he said. “People have found, ‘I can keep eating what I want to eat, and take this and I’m doing fine,’ ” he said. “We’re starting to see that if you do that, you can run into some risky side effects.”
“Many patients may be on the drugs for no good medical reason, at huge cost to the health care system, ” said Dr. Joel J. Heidelbaugh, a family medicine doctor in Ann Arbor, Mich. When he reviewed medical records of almost 1,000 patients on P.P.I.’s at an outpatient Veterans Affairs clinic in Ann Arbor, he found that only one-third had a diagnosis that justified the drugs. The others seemed to have been given the medications “just in case.”
“We put people on P.P.I.’s, and we ignore the fact that we were designed to have acid in our stomach,” said Dr. Greg Plotnikoff, a physician who specializes in integrative therapy at the Penny George Institute for Health and Healing in Minneapolis.
Stomach acid is needed to break down food and absorb nutrients, he said, as well as for proper functioning of the gallbladder and pancreas. Long-term of use of P.P.I.’s may interfere with these processes, he noted. And suppression of stomach acid, which kills bacteria and other microbes, may make people more susceptible to infections, like C. difficile.
Taking P.P.I.’s, Dr. Plotnikoff said, “changes the ecology of the gut and actually allows overgrowth of some things that normally would be kept under control.”
Stomach acid also stimulates coughing, which helps clear the lungs. Some experts think this is why some patients, especially those who are frail and elderly, face an increased risk of pneumonia if they take P.P.I.’s.
Chinese Medicine for GERD
My favorite herbal formula for GERD is Blue Poppy brand’s Gastroquell. This is a combination of two classical formulas that treat the Chinese disease categories un suan (swallowing acid), ai qi (belching), e ni (hiccup), wei wan tong (stomach duct pain), xin tong (heart pain)
These correspond to the modern western diagnosis of heartburn or GERD, and can overlap into gastritis, too. More importantly, this traditional formula has been adapted to treat the pattern of disharmony that causes GERD: Liver-spleen-stomach disharmony with depressive heat and possible food stagnation.
I use this formula when my patients have some combination of the below symptoms and or signs:
THE SIGNS AND SYMPTOMS OF LIVER DEPRESSION/DEPRESSIVE HEAT INCLUDE
- Epigastric and/or esophageal burning pain
- Acid regurgitation
- Clamoring stomach
- Ribside distention and pain
- Burping, belching, a tendency to hiccup
- A bitter taste in the mouth
- Irritability, vexation, and agitation
- A dry mouth with a predilection for chilled drinks
- A large appetite or rapid hungering
- A red tongue and/or yellow tongue fur
- A bowstring, rapid pulse
THE SIGNS AND SYMPTOMS OF SPLEEN VACUITY INCLUDE
- Fatigue, lack of strength
- Abdominal distention, especially after meals
- “Sugar blues,” a craving for sweets
- A fat, distended tongue with teethmarks on its edges
THE SIGNS AND SYMPTOMS OF FOOD STAGNATION INCLUDE
- Bad breath
- Thick, slimy tongue fur
- Nausea and/or distention after eating
- A slippery pulse
Gastroquell works in these cases because the herbs in the formula relieve the pattern hat causes the GERD.
Specifically, Chai Hu (Radix Bupleuri), Bai Shao (Radix Alba Paeoniae), Zhi Ke (Fructus Immaturus Aurantii), and Xiang Fu (Rhizoma Cyperi) course the liver and resolve depression. Huang Qin (Radix Scutellariae) and Huang Lian (Rhizoma Coptidis) clear depressive heat from the liver, gallbladder, and stomach. Sheng Jiang (uncooked Rhizoma Zingiberis), Ban Xia (Rhizoma Pinelliae), Zhu Ru (Caulis Bambusae In Taeniam), harmonize the stomach and downbear counterflow. In addition, Zhu Ru clears liverstomach heat, and Ban Xia, Bai Zhu, and Fu Ling (Poria) transform and eliminate dampness. Yin Chen Hao (Herba Artemisiae Scopariae) clears and eliminates dampness and heat from the livergallbladder at the same time as helping Chai Hu course the liver and rectify the qi, but without plundering yin. Dang Shen (Radix Codonopsis), Bai Zhu (Rhizoma Atractylodis Macrocephalae), Fu Ling, and mixfried Gan Cao (Radix Glycyrrhizae) fortify the spleen and supplement the qi. Shan Zha (Fructus Crataegi) disperses food and abducts stagnation. It also reduces cholesterol and helps reduce blood pressure.
I like using the Blue Poppy brand herbs because of their stringent testing for bacteria, heavy metals and other contaminants. From their website, “Blue Poppy products undergo one of the most comprehensive testing regimes in the industry. We are the only company in the industry to use a third-party certified FDA cGMP manufacturing facility in conjunction with third-party lab testing for every batch of every formula. We test every formula for microbiologic contaminants, heavy metals and pesticide residue.”
Acupuncture in the treatment of GERD
Acupuncture is very valuable in the treatment of digestive disorders because of its effect on the nervous system. Acupuncture takes you out of the stress response and into the relaxation response. Via the Gut-Brain connection, a lot of what underpins GERD is a somatic expression of various kinds of stressors that combine to block the free flow of Qi in the middle and lower jiao, the part of the body containing all the organs of digestion, the Liver, Gall Bladder, Stomach, Spleen, Pancreas, and Intestines.
Classical Chinese acupuncture, along with Mindfulness Based Stress Management skills, can “reset” the nervous system so that it does not interfere with healthy digestion.