Q: I take a prescription strength stomach acid medicine called Prevacid® which has helped my heartburn a lot. Now my insurance company is refusing to cover it. When I stop it, all my heartburn symptoms come back. What can I do?
Prevacid® is an acid blocking medicine called a proton pump inhibitor, or PPI. Every time you eat or drink something, a miniature pump called a proton pump shoots gastric acid into your stomach to start digesting that piece of yummy apple pie ala mode you just ate. Prevacid® and other PPIs reduce heartburn and help heal stomach ulcers by reducing the amount of gastric acid in your stomach.
PPIs are our most effective medicines for treating excessive stomach acid and are very good at helping heal ulcers. PPIs can even help prevent ulcers. People taking blood thinners like warfarin or Coumadin® together with pain medicines like ibuprofen or naproxen have less problems with bleeding ulcers if they are also taking a PPI.
Twenty-two years ago while taking the very last capsule of an antibiotic called doxycycline, it got stuck. Extra water didn’t help. I could feel a pressure beneath my breastbone right where that darn pill had stuck. Soon it felt like I was swallowing fire every time I ate or drank anything. The pain kept increasing until I ended up in the Emergency Department diagnosed with an ulcer in my esophagus, all because of a pill dissolving in the wrong place!
The ER doctor started me on a prescription medicine called Prilosec®, the very first PPI available and for the next 6 weeks spicy food was off-limits. I glumly ate yogurt while my family enjoyed the Tex-Mex food at my youngest sister Margaret’s wedding in Austin, Texas.
Is it okay to take a PPI year after year?
It seems to be safe to take a PPI for years instead of just months, but there is a price. Absorbing Vitamin B12, iron, calcium and magnesium depends on having a certain amount of stomach acid. Those who take PPIs longer than a few months risk becoming deficient in these critical nutrients. Long-term use of PPIs is also associated with an increase in bone fractures both in men and women, possibly related to absorbing less calcium.
Stomach acid is one of the most important defenses our body has against foreign organisms. Taking a PPI long-term can lead to increased infections such as pneumonia or a particular organism called Clostridium difficile that causes antibiotic-associated diarrhea.
If you’ve suffered from heartburn when stopping your PPI you are not alone. Between 60-90% of folks taking a PPI for at least 3 months notice symptoms of stomach burning when they stop taking it.
Having heartburn symptoms come back when you stop your Prevacid® doesn’t mean you’re stuck on it for the rest of your life.
Here are 3 approaches to reducing your dependence on a PPI medicine:
1. If your doctor has no objections, slowly taper the dose down over several months before stopping it. If you take your PPI twice a day, start the taper by decreasing or stopping the evening dose. If you take the PPI once a day, taper by cutting the dose in half or taking it every other day. Stay on the reduced dose for several weeks before trying another decrease.
Taper the PPI dose every few weeks until you are off it completely. If your symptoms come back, start with the last dose you were symptom-free and stay on it another few weeks before trying to taper it. For some people this may take up to 9 months.
2. Switch to an older stomach medicine like Zantac® or ranitidine to help control your symptoms. Called an H2-blocker, medicines like Zantac® work best when taken at night. Taking a PPI in the morning and rantidine (Zantac®) at night can help keep your symptoms under control while tapering your PPI.
3. If your prescription PPI taper isn’t feasible or successful, you can switch to a PPI available without a prescription such as Prilosec® OTC or Prevacid® 24HR®. Another PPI has just become available over-the-counter (OTC): Nexium® 24HR.
For occasional fast-acting relief of heartburn, antacids like Tums®, Mylanta® and Maalox® are available in liquid form or chewable tablets. These older antacid products often contain calcium or magnesium, which can interfere with absorbing some prescription medicines. Please check with your pharmacist before taking them.
