Gastroesophageal Reflux Disease (GERD) Awareness Week is a convenient time to reflect and consider why greater attention is needed. It is not just because GERD is extraordinarily common or that the number of Americans with symptoms of reflux such as heartburn is steadily growing. In fact, we have never had as many effective ways to manage GERD as we do now. The paradox is that GERD awareness is relevant now more than ever because of growing confusion about the safety of GERD treatments, leading many to abandon effective therapy, sometimes with disastrous consequences. Individuals with untreated GERD can expect a reduction in their quality of life, as well as their work productivity, and could be at increased risk for the development of esophageal cancer. Consequently, the introduction of a once-daily medication in the 1990s that could eradicate symptoms and reduce complications in nearly 7 out of 10 patients was revolutionary. It is no small wonder that proton pump inhibitors (PPIs) became the most commonly used therapy for GERD. But like many other medications, concerns have been raised for adverse events with long-term use. As a result, over the years, alternative medical, endoscopic, and surgical therapies emerged. Neither these newer alternatives, nor the older therapies, are a panacea. Recently we learned that another commonly used medication — ranitidine — has been voluntarily removed from the market over possible cancer-causing risks, making those associated with PPIs sound less concerning. So, in this sea of negative reports, what is a person with GERD to do? As gastroenterologists taking care of patients with GERD, we are increasingly concerned about the rising regularity of cautions to avoid effective PPI therapy over fears of side effects. Although the basis of these cautions is provocative, the actual risk posed by PPIs of outcomes such as dementia, bone frailty, and kidney failure is far lower than patients perceive it to be. Most often, the side effects ascribed to PPIs are more closely related to underlying medical conditions than to the medication itself. A point to consider: patients taking aspirin for heart disease have higher mortality from heart attacks than those not on aspirin. This is not because aspirin causes these complications, but because of the inherent complication rate of cardiovascular disease. Similarly, some patients on PPI therapy who report side effects may have alternative mechanisms to explain them. Finally, the increased risk reported with many of the side effects attributed to PPIs fall into what is termed a “zone of bias,” a situation when available data is not convincing enough to consider a cause-and-effect relationship. For instance, for every 1,000 women with a hip fracture compared with 1,000 without, only one more was taking a PPI at the time of the fracture. Importantly, newer well-done studies have not replicated the risk of dementia or the concerns about drug interactions that initially received so much attention. It will take prospective studies, and years of research, to fully understand the true likelihood of life-threatening side effects from PPI use, but data are emerging that appear to mitigate some of the earlier concerns. Of course, all therapeutic adventures require an assessment of the risks and benefits for each patient. Yet patients and practitioners often perceive risks of PPIs to be far more established and robust than the consequences of GERD, which range from innocuous to grave. Many, therefore, discontinue PPIs. This is inconsistent with established best practices published by the American Gastroenterological Association. It is important to remember that basic principles of medical therapeutics also apply for PPIs, and for the right patients they are the right medicine, and should be used long term at the lowest necessary dose. So, while we have no convincing data showing PPIs cause frequent long-term adverse events, we do need to understand and address the reasons why PPIs are so frequently needed. The manifest obesity epidemic is directly linked to the rising prevalence of GERD. But this also means diet, behavioral, and postural interventions can be employed to combat reflux. In some patients, though, PPI therapy or alternative treatments such as surgery remains the best option. It is troubling that some seek surgery over PPIs without considering inherent risks, both of PPI discontinuation and of the alternative approach. Post-operative side effects are not uncommon, and many will still require PPIs even though they sought surgery to avoid them in the first place. Ultimately, we believe gastroenterologists are in the best position to help with the difficult choices patients face. Even though many reflux medicines are available without a prescription, those using chronic anti-reflux therapy should tell their doctor to facilitate an informed discussion. While we should not lose sight of why so many suffer from GERD, and that lifestyle modification can profoundly impact symptoms, in most patients, the benefits of effective management with PPIs outweigh the potential risks of long-term use. RELATED: Are Heartburn Drugs Safe? David Leiman, MD, is an assistant professor of medicine in the division of gastroenterology at the Duke Clinical Research Institute of Duke University Medical Center in Durham, North Carolina. Karthik Ravi, MD, is an associate professor of medicine in the division of gastroenterology at the Mayo Clinic in Rochester, Minnesota. C. Prakash Gyawali, MD, is a professor of medicine at the Washington University School of Medicine in St. Louis, Missouri. Drs. Leiman and Ravi, as well as their mentor, Dr. Gyawali, are specialists in esophageal disorders and are members of the American Gastroenterological Association (AGA) Future Leaders program, which provides a pathway for leadership development within AGA for early-career physicians and scientists who have the potential to make a significant impact on the specialty. Learn more at the AGA website.
