Proton-Pump Inhibitors Highly Recommended for Barrett’s Esophagus
DEAR DR. ROACH: I am a retired male over 65 and a former occasional cigar smoker. I quit 15 years ago after I was diagnosed with Barrett’s esophagus. I was also a former drinker and quit seven years ago. I regularly completed all the biopsies as required and took my proton-pump inhibitor (PPI) daily as instructed.
This year, I read an article about PPIs contributing to dementia and neuropathy, which I have. My primary care physician suggested that I switch to over-the-counter H2 blockers as a safer approach. I developed an irregular heart rhythm and soaring blood pressure.
I was then diagnosed with atrial fibrillation (AFib). My stress test and echocardiogram are normal for my age. I am now on some heavy-duty beta blockers, blood thinners and a very expensive rhythm-control drug.
A book I recently read written by two top cardiologists stated that long-term use of PPIs is dangerous and can cause AFib, but a recent article published by the National Institute of Health states the opposite. I also read that an irritated esophagus stimulates the esophagus nerve and triggers AFib. I’m confused now.
Because Barrett’s vastly increases my chances for getting a very aggressive cancer, doing nothing is not an option. I have already modified and continue to modify my diet, but that only goes so far. And as I’m sure you are aware of, a stroke caused by AFib is often life-threatening.
My complicated question is, which professional approach would you recommend: PPIs or H2 blockers? Is there a third option? -- B.B.
ANSWER: There is not a definitive answer on whether PPIs, like omeprazole, increase the risk of AFib. Studies are potentially confounded by the fact that people with AFib sometimes think they have stomach problems and may take a PPI, leading to a false association between the PPI and AFib. As you say, there have also been studies that suggest a decreased risk of AFib in people who use PPIs.
In my mind, the increased risk of adenocarcinoma of the esophagus as a result of untreated stomach acid reflux in a person with Barrett’s esophagus is the key in this situation, as Barrett’s is a condition where abnormal lining of the esophagus occurs due to years of acid exposure.
I do not believe over-the-counter H2 blockers, like famotidine (Pepcid), are adequate enough to reduce the risk of esophageal cancer, so I advise patients in your situation to use PPIs, despite their known risks.
The data suggesting a risk of dementia are weak. While there might be a small risk, the risk isn’t high enough to avoid using a PPI in a person with Barrett’s. B12 deficiency is absolutely a risk in people taking long-term PPIs. Low B12 can certainly lead to neuropathy, but both can be prevented and treated by testing for B12 deficiency and by getting supplementation, if needed.
I am very glad to hear you are getting routine endoscopic surveillance and biopsies so that any abnormal growth of the esophagus can be identified and treated promptly.
Dr. Roach regrets that he is unable to answer individual questions, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@ med.cornell.edu.
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