A hidden side to wonder drugs
Awise physician once observed: “When I hear of the latest ‘wonder drug’, I always ‘wonder’ what its adverse effects will turn out to be.” He was cautioning against their too ready adoption over the tried and tested. But sometimes, if rarely, the “wonder drug” is so demonstrably superior to the standard treatment to be irresistible – as with the introduction of the acid suppressant omeprazole in the 1980s.
Ten years earlier, when I was a junior doctor, the only reliably effective cure for recurrent stomach ulcers entailed a major abdominal operation to snip away the branches of the vagus nerve that stimulate the release of acidic secretions – followed by 10 days in hospital for the wound to heal and the bowel functions to return to normal.
Then, a brilliant pharmacologist discovered a chemical that blocks the action of the proton pump, which sends the acidic hydrogen ions from within the acid-secreting cells into the stomach cavity. It was a beautifully elegant solution abolishing the need for those heroic abdominal operations in favour of a once-daily dose of a proton pump inhibitor (PPI). A wonder drug, indeed – with the added bonus that the drug’s targeting of the proton pump was so specific, it was unlikely to interfere with the functioning of organs or tissues elsewhere in the body.
Given this impressive efficacy and safety, it seemed entirely reasonable to extend the indications for its use. Many commonly prescribed medicines (aspirin, antiinflammatories, steroids, etc) irritate the lining of the stomach, exposing it to those fierce acidic secretions. So by reducing their concentration with omeprazole, patients were much less likely to experience dyspepsia or be exposed to the small but potentially serious hazard of internal bleeding.
This “protective” effect of PPIS against the side-effects of those commonly prescribed drugs has long since become the commonest reason for people to take them; PPIS are now routinely added to the prescriptions of millions. And why not, one might think? The problem being that, when taken by millions, the adverse consequences of PPIS own, if certainly rare, side-effects can be substantial.
Thus the high acidity of the stomach serves other functions than aiding the digestion of food, including killing 99 per cent of bacteria – whose survival in a low acidic environment can predispose to bowel infections. PPIS can also, it has emerged, interfere with the absorption of calcium and magnesium, predisposing respectively to thinning of the bones (osteoporosis) and disturbances of heart rhythm.
Still, the practice of routinely adding PPIS to patients’ prescriptions is so deeply entrenched, it has proved difficult to persuade doctors to think twice before doing so. Two recent developments might change that. First, the suspicion that, taken long-term, they can subtly damage the internal lining of the blood vessels, predisposing to atherosclerosis (hardening of the arteries), would seem to be confirmed by an authoritative study published last month that they increase the risk of a heart attack twofold. Next, the sheer scale of over-prescribing is revealed by a concerted effort by 25 surgeries in Britain to reduce their use. This is not easy, mainly because the proton pump after being inhibited by PPIS for some time tends to go into a
compensatory overdrive when they are stopped, resulting in a rebound of those acidic secretions to cause severe dyspepsia and heartburn. This can be avoided by temporarily substituting an antacid such as Gaviscon. Having encouraged the 6,000-plus patients on their books taking PPIS to adopt this regime, they were able to reduce the dose or discontinue them altogether in a staggering 75 per cent of cases.
My holiday hell
This week’s query comes courtesy of Mrs JP from Dorset, afflicted when working in a stressful job with twice-weekly migraine attacks. Since retirement these have almost disappeared – other than in one puzzling circumstance. “Whenever returning from holiday, even if I have only been away a couple of days, I know that within 24 hours, I will get the familiar symptoms of sickness and severe headache,” she writes. How, she asks, might she prevent this happening?
When taken by millions, the adverse consequences can be substantial