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Transcript

The Gut Medication Most Patients Stay On Too Long · The Gastro Truth with Dr. Mel Ona

• 0:00
  SPEAKER_00: Most patients taking a proton pump inhibitor have never been told something important.
• 0:05
  SPEAKER_00: This medication was designed to be used for 8 to 12 weeks.
• 0:10
  SPEAKER_00: Most of them have been on it for years, some for a decade or more, and in most cases, nobody has sat down with them to ask whether they still need it.
• 0:18
  SPEAKER_00: I'm Dr.
• 0:19
  SPEAKER_00: Mel Ona, a board certified gastroenterologist in Hawaii.
• 0:22
  SPEAKER_00: I have a master's degree in nutritional biochemistry and I've worked with over 10,000 patients with digestive conditions.
• 0:29
  SPEAKER_00: Now, proton pump inhibitors, or PPIs, are one of the most prescribed medication classes in the country.
• 0:35
  SPEAKER_00: Omeprazole, lanzoprazol, pantroprazol, isomeprazol, they reduce the amount of acid your stomach produces.
• 0:42
  SPEAKER_00: They work.
• 0:43
  SPEAKER_00: For the right indication, used for the right length of time, they're effective and appropriate.
• 0:48
  SPEAKER_00: The conversation about stopping, though, rarely happens.
• 0:52
  SPEAKER_00: And that gap has real consequences for the gut.
• 0:55
  SPEAKER_00: Now in this video, I'll show you what your stomach acid is actually doing, what happens when it's suppressed for years, and what the conversation about stopping looks like when someone finally has it.
• 1:06
  SPEAKER_00: Now, why this conversation doesn't happen?
• 1:09
  SPEAKER_00: There's a structural reason most patients stay on PPIs indefinitely.
• 1:13
  SPEAKER_00: It has nothing to do with their doctor making a mistake.
• 1:16
  SPEAKER_00: Now, PPIs are often prescribed at a moment of acute need, a severe reflux episode that lands someone in the ER, a surgery where stomach protection is standard protocol, an H.
• 1:28
  SPEAKER_00: pylori infection being treated with antibiotics.
• 1:31
  SPEAKER_00: In all of these situations, the prescribing doctor is focused on the immediate problem.
• 1:36
  SPEAKER_00: The follow-up conversation, when to stop, what to watch for, how to taper, doesn't always happen in that same appointment.
• 1:43
  SPEAKER_00: And then refills begin.
• 1:45
  SPEAKER_00: Most pharmacies process them automatically.
• 1:47
  SPEAKER_00: The patient picks up a 90-day supply without seeing a doctor.
• 1:51
  SPEAKER_00: Their primary care physician renews the prescription because stopping requires a separate conversation.
• 1:56
  SPEAKER_00: And that conversation takes more than 15 minutes, so it gets pushed.
• 2:00
  SPEAKER_00: Now there's also a real biological reason stopping is hard, which I'll explain later.
• 2:05
  SPEAKER_00: But the short version is this stopping PPIs without a plan causes a rebound in acid production that feels worse than the original problem.
• 2:13
  SPEAKER_00: Patients try to stop, feel terrible, and restart.
• 2:17
  SPEAKER_00: The rebound keeps them on the drug and the prescription keeps renewing.
• 2:21
  SPEAKER_00: What ends up on file is a patient on a PPI for years.
• 2:24
  SPEAKER_00: The original indication resolved in weeks.
• 2:27
  SPEAKER_00: No one ever explained what the medication does to the rest of the gut over time and what stomach acid is actually doing.
• 2:33
  SPEAKER_00: Before explaining what happens when acid is suppressed for years, it helps to understand what stomach acid is doing that most people don't know about.
• 2:40
  SPEAKER_00: Most people think of stomach acid as a digestion tool, and it is.
• 2:44
  SPEAKER_00: But it's also one of your gut's main defense systems.
• 2:47
  SPEAKER_00: Your stomach acid sits at a pH between 1.5 and 3.5.
• 2:51
  SPEAKER_00: That's hostile enough to kill most bacteria before they can travel farther into your digestive tract.
• 2:56
  SPEAKER_00: Bacteria that make it into your mouth or your food are mostly destroyed in the stomach.
• 3:01
  SPEAKER_00: They don't reach the small intestine.
• 3:03
  SPEAKER_00: The small intestine is supposed to be a low bacteria environment.
• 3:07
  SPEAKER_00: It's where your nutrients get absorbed.
• 3:09
  SPEAKER_00: Your large intestine, farther down, is where most of your gut bacteria live and do their work.
• 3:15
  SPEAKER_00: That separation exists because the acidic stomach acts as a checkpoint.
• 3:19
  SPEAKER_00: When that checkpoint drops, bacteria that would normally be killed in the stomach survive.
• 3:24
  SPEAKER_00: They migrate into the small intestine where they don't belong.
• 3:27
  SPEAKER_00: That migration is the starting point for most of the downstream effects of the long-term PPI use.
• 3:33
  SPEAKER_00: So what happens to the gut?
• 3:35
  SPEAKER_00: The most direct effect is an increased risk of bacterial overgrowth in the small intestine, what gastroenterologists call SIBO.
• 3:42
  SPEAKER_00: Multiple meta-analyses show that long-term PPI use significantly increases this risk.
• 3:47
  SPEAKER_00: The acid checkpoint is gone.
• 3:49
  SPEAKER_00: Bacteria migrate up and they begin fermenting food in a place where fermentation isn't supposed to happen.
• 3:54
  SPEAKER_00: The result is bloating, gas, and cramping.
• 3:57
  SPEAKER_00: Most patients attribute these symptoms to everything except the medication.
• 4:01
  SPEAKER_00: Now, beyond SIBO, long-term PPI use shifts the broader gut microbiome in ways that compound over time.
• 4:08
  SPEAKER_00: Studies comparing the microbiomes of long-term PPI users to non-users show a consistent pattern.
• 4:14
  SPEAKER_00: PPI users have higher populations of bacteria normally found in the mouth and throat, including Streptococcus and valenella, showing up in the gut.
• 4:23
  SPEAKER_00: Microbial diversity drops, and the risk of Clostridioides difficile infection, or C.
• 4:28
  SPEAKER_00: diff, roughly doubles in long-term PPI users.
• 4:32
  SPEAKER_00: A C.
• 4:32
  SPEAKER_00: diff causes severe intestinal infection.
• 4:35
  SPEAKER_00: It produces persistent diarrhea and cramping.
• 4:37
  SPEAKER_00: In vulnerable patients, it can be life-threatening.
• 4:40
  SPEAKER_00: The nutrient effects are a separate chain.
• 4:42
  SPEAKER_00: Stomach acid is required for the absorption of several key minerals and vitamins.
• 4:47
  SPEAKER_00: Magnesium absorption drops on long-term PPI therapy.
• 4:50
  SPEAKER_00: The FDA issued a safety warning about low magnesium in 2011 for patients on PPIs for more than a year.
• 4:57
  SPEAKER_00: Now low magnesium affects muscle function, nerve signaling, and heart rhythm.
• 5:01
  SPEAKER_00: Vitamin B12 absorption also requires an acid environment.
• 5:05
  SPEAKER_00: The protein that carries B12 into the bloodstream, called intrinsic factor, depends on acid to function.
• 5:11
  SPEAKER_00: Long-term PPI use is associated with B12 deficiency, and that deficiency can cause fatigue, nerve damage, and cognitive symptoms.
• 5:18
  SPEAKER_00: Now these build slowly enough that the connection to the medication often gets missed.
• 5:22
  SPEAKER_00: Now calcium absorption is affected as well.
• 5:25
  SPEAKER_00: Calcium carbonate, the most common supplement form, needs acid to dissolve before it can be absorbed.
• 5:30
  SPEAKER_00: Long-term PPI use is associated with lower bone density and a higher risk of hip fracture.
• 5:36
  SPEAKER_00: Now the FDA issued a separate safety communication about this in 2010.
• 5:40
  SPEAKER_00: Multiple large epidemiological studies in the mid-2010s also found an association between long-term PPI use and chronic kidney disease.
• 5:48
  SPEAKER_00: Now the mechanism isn't fully established, but the association is consistent across studies involving hundreds of thousands of patients.
• 5:55
  SPEAKER_00: So none of these risks are hidden.
• 5:57
  SPEAKER_00: They're in the literature, they're in the FDA warnings, and there's something most gastroenterologists know.
• 6:03
  SPEAKER_00: They rarely make it into the appointment where the prescription gets renewed.
• 6:06
  SPEAKER_00: That appointment is usually a routine visit focused on something else.
• 6:10
  SPEAKER_00: The PPI has been on the medication list for so long that it doesn't get questioned.
• 6:14
  SPEAKER_00: So if this is the kind of thing you want to keep hearing, subscribe.
• 6:18
  SPEAKER_00: I put out a new video every week on gut health and digestive medicine.
• 6:22
  SPEAKER_00: The things a 15-minute GI appointment can't cover.
• 6:25
  SPEAKER_00: This channel covers in depth the rebound trap.
• 6:28
  SPEAKER_00: Now here's the part that keeps patients stuck.
• 6:31
  SPEAKER_00: And it's worth understanding before making any changes.
• 6:34
  SPEAKER_00: When you take a PPI, your stomach responds to the lower acid environment by producing more of a hormone called gastrin.
• 6:41
  SPEAKER_00: Gastrin's job is to stimulate acid secretion.
• 6:44
  SPEAKER_00: Your body is trying to compensate for the acid drop by turning up the signal that drives acid production.
• 6:50
  SPEAKER_00: And while you're on the PPI, that compensatory response stays suppressed.
• 6:55
  SPEAKER_00: The moment you stop, the elevated gastrin drives a surge in acid.
• 6:59
  SPEAKER_00: That surge can be significantly worse than what you had before you started the medication.
• 7:03
  SPEAKER_00: Now this is called rebound acid hypersecretion.
• 7:07
  SPEAKER_00: It's real and well documented.
• 7:09
  SPEAKER_00: The surge typically peaks in the first one to two weeks after stopping, and it resolves over four to eight weeks.
• 7:16
  SPEAKER_00: But most patients who try to stop cold turkey don't know that.
• 7:19
  SPEAKER_00: They experience the rebound, assume the drug is still necessary, and restart it.
• 7:24
  SPEAKER_00: Now this cycle is what keeps so many patients on a medication they no longer need.
• 7:28
  SPEAKER_00: The way to get off a PPI when it's no longer needed is to taper rather than stop abruptly.
• 7:34
  SPEAKER_00: Reducing the dose over four to eight weeks gives gastrin levels time to normalize.
• 7:38
  SPEAKER_00: Now an H2 receptor blocker like Fomotidine, the active ingredient in pepsid, used as a bridge during the taper gives the stomach something to fall back on without triggering the same compensatory response.
• 7:49
  SPEAKER_00: Smaller meals, nothing to eat within two to three hours of bedtime, and elevating the head of the bed help reduce the acid load during the transition.
• 7:57
  SPEAKER_00: Now one important clarification: if you have documented erosive esophagitis, Barrett's esophagus, or severe gastroesophageal reflux disease or GERD, with confirmed esophageal damage, long-term PPI use may genuinely be appropriate.
• 8:12
  SPEAKER_00: Now that's a conversation to have with your gastroenterologist with your actual test results in front of you.
• 8:16
  SPEAKER_00: This video is for the much larger group of patients who started a PPI for a short-term reason: a painful reflux episode, a stomach ulcer, a course of antibiotics for H.
• 8:25
  SPEAKER_00: pylori infection.
• 8:26
  SPEAKER_00: The original reason resolved, but no follow-up conversation about stopping ever happened, and years have passed.
• 8:33
  SPEAKER_00: What to do with this information?
• 8:35
  SPEAKER_00: The first move is to find out when you started and what the original indication was.
• 8:40
  SPEAKER_00: Your pharmacy can pull the date.
• 8:42
  SPEAKER_00: Your prescribing doctor's records will have the original reason.
• 8:45
  SPEAKER_00: If the original indication was a peptic ulcer, it heals in 8 to 12 weeks.
• 8:50
  SPEAKER_00: It doesn't require ongoing acid suppression.
• 8:53
  SPEAKER_00: If it was pre-surgical, the surgery is done.
• 8:56
  SPEAKER_00: If it was H.
• 8:56
  SPEAKER_00: pylori, a follow-up breath test or stool antigen test can confirm whether the infection was cleared.
• 9:02
  SPEAKER_00: The second move is to bring this question to your doctor directly.
• 9:05
  SPEAKER_00: A useful way to frame it, I've been on this medication for X years.
• 9:09
  SPEAKER_00: Can we talk about whether I still need it and what stopping would look like?
• 9:13
  SPEAKER_00: That framing invites the conversation without putting the doctor on the defensive.
• 9:17
  SPEAKER_00: If the answer is you should stay on it, ask what the specific current indication is.
• 9:22
  SPEAKER_00: That question alone moves things forward.
• 9:25
  SPEAKER_00: The third move, if you and your doctor agree to try stopping, is to do it with a plan.
• 9:29
  SPEAKER_00: Now don't stop abruptly.
• 9:31
  SPEAKER_00: Ask about a tapering schedule.
• 9:33
  SPEAKER_00: Ask whether an H2 receptor blocker would help during the transition.
• 9:37
  SPEAKER_00: Give yourself four to eight weeks before drawing conclusions about whether you still need the medication.
• 9:42
  SPEAKER_00: Now the rebound is temporary.
• 9:44
  SPEAKER_00: Getting through it is how you find out whether the original problem is still there.
• 9:48
  SPEAKER_00: And if you've been on a PPI for more than a year and you've noticed new gut symptoms during that time, bloating, increased susceptibility to infections, fatigue, unexplained changes in bowel habits, it's worth raising the medication as a possible contributor, not a certainty.
• 10:04
  SPEAKER_00: A question worth asking.
• 10:05
  SPEAKER_00: Most patients on long-term PPIs aren't on them because their doctor reviewed the risks and decided the benefits outweigh them.
• 10:12
  SPEAKER_00: They're on them because nobody stopped to have the conversation.
• 10:16
  SPEAKER_00: Having that conversation now, even years in, still changes what happens next.
• 10:21
  SPEAKER_00: The gut responds to the change faster than most people expect.
• 10:24
  SPEAKER_00: Now, if you want to understand what else might be running in the gut that diet and lifestyle aren't fixing, there's a video on this channel that covers exactly that.
• 10:33
  SPEAKER_00: It's called How Eating Clean Can Make Your Gut Worse.
• 10:36
  SPEAKER_00: Watch that one next.