Stomach acid must be Public Enemy #1 for gastroenterologists and primary care physicians. Why else would more than 10 million Americans swallow proton pump inhibitor (PPI) medicines each day? These medicines are potent stomach acid blockers. Common examples of these medicines include Prilosec (omeprazole), Nexium (esomeprazole) and Protonix (pantoprazole). PPI medicines have generated tens of billions of dollars for pharmaceutical companies. And several of these medicines are available over-the-counter (OTC), which permits the public to self-prescribe for a variety of ailments.
Are ordinary folks selecting these medicines appropriately
when they purchase OTC? I have my doubts
particularly since medical professionals often prescribe these agents very
liberally going beyond the boundaries of medical evidence. I have also been culpable of the
transgression of PPI mission creep.
Indeed, studies have shown that physicians prescribe these acid blockers
for the wrong reason and also maintain patients on them for too long, which may be indefinitely. I have taken on new
patients, for example who have been on these medicines for so long that they
cannot even recall their purpose or their efficacy. Often, these medicines are started during a
hospitalization and are continued after discharge and then may be granted
eternal life.
These drugs are life-changing for patients with frequent
heartburn and gastroesophageal reflux disease, known as GERD. They are also extremely effective in treating
peptic ulcers. And they are an important
component of treating or even preventing acute internal bleeding in hospitalized
patients. But PPI use, or overuse, has
reached far beyond these drugs’ established indications.
Why has this happened?
The phenomena of drug overuse is much less common in hypertension or
diabetes, for example. Here’s the difference. Abdominal pain, indigestion, upset stomach,
abdominal cramps, nausea, and bloating are among the most common symptoms that
patients suffer from. The reality is
that at a huge percentage of these individuals will not be found to a have a
specific diagnostic explanation, such as an ulcer or gallstones or appendicitis. Many will be told that their symptoms are ‘functional’
or the effects of irritable bowel syndrome, a stubborn syndrome associated
with a variety of chronic intestinal distress.
And modern medicine doesn’t have very effective drugs for these
conditions. Medical professionals,
therefore, often prescribe PPIs in these instances hoping to bring patients a
measure of relief.
But is this practice good medicine? Should well meaning medical professionals
like me prescribe drugs outside of the drugs' reach because there are no
effective drugs available? What would the medical profession look like if all medicines were prescribed this loosely?
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