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marioncole
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Quote marioncole Replybullet Calendar Event: Slippery elm alternatives to PPI's?
    Posted: 07áJaná2018 at 12:51pm
Does anyone know if there are any alternatives to taking PPI's on an permanent basis (i take 40mg daily and have been on it for years)? I am concerned about the long term side effects of this medication. I have been looking at slippery elm and wondered if anyone had any info or knew of any validated research anywhere that indicated this might be an alternative.
Thanks
Marion
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chrisrob
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Quote chrisrob Replybullet Posted: 07áJaná2018 at 2:09pm
Hi Marion and welcome to the forum.

Continual medication with PPIs is the best course of treatment for those of us with Barrett's Oesophagus.

The popular press loves scare stories so you will see occasional reports blaming PPIs for all sorts of things: Chronic Kidney Disease, Dementia, Myocardial Infarction, Gastric Cancers etc...
The truth is, when you look at the papers they use for their source material, they usually refer to specific cohorts of patients who will have confounding factors and show a correlation rather than cause. (See this page of the free Down With Acid encyclopaedia.)
PPIs are the most widely prescribed drugs worldwide probably saving the lives of millions in the 30 years they have been available.

A meta-analysis f all research on the subject in 2014 found "PPI use was associated with a 71% reduction in risk of OAC [Cancer] and/or BO-HGD [Dysplastic Barrett's] in patients with BO."

Because of all the scare stories (mainly in US as a backlash against high drug prices), the American Gastroenterology Association commissioned a team of highly qualified experts to assess the benefit to risk ratio of taking PPIs. You may read their findings in a Special report here. It concluded, "The controlled evidence that PPIs are safe and effective for acute relief of heartburn, healing of esophagitis and peptic ulcers, and other specific treatment goals for which they are indicated is exceptional. ... The consistency of the efficacy and safety in the multicenter trials on which these indications are based provides a strong foundation on which to reassure patients likely to benefit from these therapies."

So why would you want an alternative?

As far as Slippery Elm goes, it can act as a demulcent. That is it can cause the oesophagus to produce extra mucus to help protect and act as a soothing balm to oesophagitis. But it has no medical properties to reduce acid or reflux.
There is only a passing reference to it in the Down With Acid book here as no valid research results could show efficacy.
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marioncole
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Quote marioncole Replybullet Posted: 14áJaná2018 at 3:01pm
Thank you for such a quick and detailed reply together with some other information which I will check out and read. I do worry about the long term effects of taking the medication particularly as I am on a high(ish) dosage of 40mg daily. But guess I am fortunate that I finally got a diagnosis as this is something I have had all my life.
Thank you for taking the time to respond
Marion
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Quote chrisrob Replybullet Posted: 14áJaná2018 at 3:29pm
All the best Marion.

40mg is the normal high dose. You could try reducing to 20mg - the normal maintenance dose an possibly supplement this with ranitidine at night if required. (Discuss it with your doctor.)

I was on omeprazole for 15 years, increasing to 80mg daily for the last few prior to fundoplication.
With the high dose over a sustained period, I did become anaemic through induced hypochlorhydria.
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roganhen
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Quote roganhen Replybullet Posted: 19áJaná2018 at 12:58pm
Hi Marion,
The problem with PPIs is that they do not stop reflux only change the PH. I have to use Gaviscon tablets in addition because they contain alginate which is a rafting agent. I have tried slippery elm but it does not seem as effective. However slippery elm lozenges, as used by professional singers, are very effective at soothing the oesophagus and I have found them to be really helpful after an endoscopy with biopsies
I use slippery elm lozenges if my oesophagus feels irritated and they are work for me.
I have tried slippery elm food as an evening drink on the grounds that it might make any reflux at night less irritating but it did not do a lot for me.
Best wishes,
Roganhen
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marioncole
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Quote marioncole Replybullet Posted: 20áJaná2018 at 1:07pm
Thank you - will talk to my doctor. I have also ordered the Down with Acid book. I hadn't realised that PPIs were a limited solution in that they don't deal with all the problems.

Many thanks for your help -so glad I had found this forum as the doctors/consultants don't really seem that keen on discussing overall management or long term effects.

Thank you
Marion
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marioncole
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Quote marioncole Replybullet Posted: 20áJaná2018 at 1:10pm
Hi Roganhen
I hadn't realised (and have never been told) that PPIs don't stop the reflux although my doctor had told me to take Gaviscon as well but didn't explain why.
I will try the lozenges and see if they help
Thank you for making the time to reply

Best wishes
Marion
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marioncole
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Quote marioncole Replybullet Posted: 02áFebá2018 at 12:47pm
Hi Chris
I have now received and read Down with Acid. An excellent book and so well written. It contains all the information I need to know and only wish I had read it years earlier.

My congratulations and thanks to you for producing it.

Best regards
Marion
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Jeannie
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Quote Jeannie Replybullet Posted: 25áFebá2018 at 11:57am
Hi Chris and all

After reading yet another scare story re kidney disease associated with PPI's I was wondering if I could reduce my 20 mg per day of PPI. I decided to have a word with my GP and she has now prescribed me a trial of 10 mg per day with me deciding after a month whether it is working. I am about 3 weeks into the trial and am finding that I am having breakthrough of acid reflux so have been taking quite a few Gaviscon Advance tablets mainly at night. Whereas with the 20 I only had to do this occasionally. My questions are:

Am I being over-worried about the PPI side-effects and should continue with the 20?

Should I stick with the 10 and ask the GP for a strong Ranitidine to go with it for the night times?

would appreciate thoughts from Chris and anyone else who have thoughts on this. GP didn't seem to know an awful lot about BO so would welcome thoughts from on here to help me decide.
Thanks
Jeannie

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Quote chrisrob Replybullet Posted: 25áFebá2018 at 4:51pm
Hi Jeannie,

I don't personally think PPIs cause kidney disease (CKD).

I'm guessing the recent research you refer to is this one: The association of proton pump inhibitors and chronic kidney disease: cause or confounding? which concludes: "The constellation of evidence from all available studies suggests that PPI use is associated with increased risk of adverse kidney outcomes. Exercising vigilance in the use of PPI is warranted."
But we have to understand the precise way researchers use language. The studies they reviewed showed an association. That means there were more people taking PPIs who developed CKD than who weren't. It does not say PPIs caused the CKD.
The advice to "exercise vigilance" essentially means watching patients on PPIs and being on the lookout for possible associated conditions.

This paper, Pharmacoepidemiology for nephrologists: do proton pump inhibitors cause chronic kidney disease? published last year was much more thorough and reviewed the papers that had been produced. In their conclusions the research team says, "we do not believe that these papers ... provide strong evidence of a causal link with CKD." Furthemore, they are led to provide this cautionary note: "Stopping PPIs can cause an exacerbation of severe dyspeptic symptoms, and inevitably some patients may suffer more severe complications, for instance, upper GI bleeding (as one of the high-risk consequences), after cessation."

The most common causes of CKD are Diabetes (high blood sugar - frequently associated with being overweight) and Hypertension (high blood pressure - frequently associated with being overweight).
The most common cause of acid reflux requiring PPI therapy is malfunctioning lower oesophageal sphincter most commonly caused by hiatus hernia frequently associated with being overweight.

So you can see how common confounding may be. Those overweight may develop CKD and may also require PPI. It is not the PPI that cause their CKD.
It is interesting how these stories are popularised by US media where patients look for something to blame other than their own lifestyle and dietary choices.

Please note. By providing the above exampple I am in no way attempting to infer you are overweight.

The advice though is to take the minimum necessary dose. 20mg is the normal low maintenance dose and it's fine to stay on it. If you can manage on just 10mg, by all means reduce but if you then find you need to supplement with other medication, you were probably better off before.

Incidentally, although deaths to CKD are rising, the Kidney Disease Association does not consider this correlates with the 30 year use of PPIs.

Don't blame the GPs for not knowing a lot about BO. Their training includes hundreds of possible ailments and they can't specialise in everything. And new research is always coming out. This page of the Barrett's Wessex website has shortcuts to the most recent. Remember, the 56 listed there for February so far, are just one of the hundreds of ailments the GP cannot be expected to keep up to date with.

All the best
Chris
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