The studies are part of a special theme issue of the Archives of Internal Medicine, the first in a new series examining the downside of overusing medical care.
Mitchell Katz, MD, the director of the San Francisco Department of Public Health and author of an editorial accompanying the studies, estimates that 30% to 40% of the people who take proton pump inhibitors need them for health problems such as ulcers and Barrett’s esophagus, a precancerous condition in which the lining of the esophagus is damaged by excess stomach acid.
But the remaining 60% to 70%—who take the drugs for more common conditions such as indigestion and heartburn—probably don’t need them or should try lifestyle changes before resorting to medication, he adds.
“As a culture, we tend to want a pill to deal with our problems, when a lot of people could reduce their heartburn by eating smaller meals, drinking less alcohol, or not smoking,” Dr. Katz says. “Clearly there are people who benefit. But when 60% to 70% of people don’t need to be taking it, that’s a huge problem.”
Drug manufacturers (including AstraZeneca, the maker of Nexium) could not be reached for comment.
According to Dr. Katz, the “risk-benefit ratio” of proton pump inhibitors has shifted in recent years. “When [proton pump inhibitors] first came out, people felt they had no side effects,” he says. “Now you’re talking about increased fractures, increased C. difficile infection, increased rates of pneumonia. The balance has changed.”
Indeed, another study in the journal found that proton pump inhibitors increased the risk of certain bone fractures. Researchers analyzed data on more than 161,000 postmenopausal women from around the country and found that taking proton pump inhibitors increased the risk of spine fractures by 47% and forearm and wrist fractures by about 25%.
It’s not clear why the long-term use of proton pump inhibitors might lead to more broken bones. In the study, PPI use did not appear to affect bone mineral density.
According to the researchers, suppressing stomach acid may interfere with the ability of the intestine to absorb calcium, a mineral critical to keeping bones strong. Women in their postmenopausal years are often urged to take calcium supplements to counter the inevitable effects of aging on bones, but in the study, calcium supplements didn’t seem to have an effect on the number of fractures.
Taken together, these studies suggest that proton pump inhibitors are overprescribed, Dr. Katz says.
And when they are prescribed, the doses may be too high. Yet another study, a meta-analysis of seven clinical trials involving about 1,150 patients with bleeding ulcers, found that higher doses of proton pump inhibitors did not reduce the risk of additional bleeding, need for surgery, or death more effectively than lower doses did.
Proton pump inhibitors “reinforce the idea that the solution to behavioral health issues is to take a pill, and that’s just not how we’re going to get healthier,” says Dr. Katz. “Consumers need to ask their doctors, ‘Why am I taking this? Do I still need this? Do I have an alternative?’”
