Why PPIs are a Poor Silent Reflux Treatment
Proton-pump inhibitors (PPIs).
They do not work better than placebo as silent reflux treatment.
Still, they get prescribed like crazy.
Most doctors simply take what works for GERD and tell people with silent reflux to use the same.
What are Proton-Pump Inhibitors?
Proton-pump inhibitors are massively reducing the acid production of your stomach.
Here are the brand names that they are currently sold under. In the brackets is the generic name of the medication.
- Nexium (Esomeprazole)
- Prilosec (Omeprazole)
- Prevacid (Lansoprazole)
- Dexilant (Dexlansoprazole)
- Protonix (Pantoprazole)
- AcipHex (Rabeprazole)
The Typical Reflux Patient Has Heartburn
Most doctors treat refluxers who have GERD (short for gastroesophageal reflux disease).
People with GERD have their problems in their esophagus. The reflux gets there in liquid form and damages the mucous membrane. The results are pain (heartburn) in the short term and more serious risks – like cancer – in the long term.
If you have silent reflux, however, you do not get heartburn. Many people do not feel pain at all – or at least it’s only minor. That is why it is called “silent” reflux.
Proton-Pump Inhibitors (PPIs) Work against GERD…
GERD is usually treated with PPIs, short for proton-pump inhibitors.
These medications decrease the acid production in the stomach.
For GERD, they work really well. Most patients recover from their symptoms in a few weeks. Also, PPIs are very safe when used only for a few weeks.
This is why doctors like to prescribe PPIs if a patient has heartburn.
…but PPIs Don’t Work Better than Placebo as a Silent Reflux Treatment
PPIs only decrease the acid that your reflux contains. The reflux itself still happens.
For GERD, that is not such a big deal. The acid inflicts the most damage. So the PPIs help.
For silent reflux that is different.
In recent years, researchers discovered: stomach acid plays only a minor role for most silent reflux symptoms.
What is causing the most damage are the so-called pepsins – a type of stomach enzymes. They help to digest proteins.
When you take PPIs, the pepsin level in your reflux is pretty much the same. So they can still do all the damage when you reflux.
That explains studies which show that PPI do not work better against silent reflux than placebo.
Reflux expert Professor Peter Dettmar backs that up in my interview with him.
So why do doctors still prescribe PPIs like crazy as a treatment for silent reflux?
Doctors Do Not Treat GERD and Silent Reflux as Different Diseases
Many people seek medical attention for heartburn. And doctors know how to treat that one.
Silent reflux, however, is something very new for a lot of medical professionals. 99% of the physicians or even researchers did not know about it till a few years ago. We just start to understand how silent reflux is caused.
The medical knowledge increases WAY faster than any doctor could keep up with. That is why silent reflux is still a blank spot for most physicians.
So when a doctor sees a patient with silent reflux, he will need to make an educated guess. That means taking the knowledge that he has and “guesstimating” how to treat silent reflux correctly.
The logical chain of most doctors is simple: silent reflux is just reflux in the end. PPI work against “normal” reflux. So PPIs should also work as a silent reflux therapy.
The problem is, this logic leaves out the important fact of the stomach enzyme pepsin being the primary cause of silent reflux symptoms.
PPI Test Treatments are Ineffective
Very often PPIs are used as a testing tool for GERD patients.
If a two-week treatment helps, GERD is the likely reason of the symptoms. If not, it’s probably something else.
This kind of testing-by-treating is much faster, more comfortable and cheaper than other testing methods.
In the same manner, many doctors want to use PPIs as a test for silent reflux.
However, that does not work.
As we have already discussed, PPIs do not work better than placebo against silent reflux. So treating with PPIs does not provide any information on whether you have silent reflux or not.
What is dangerous: many doctors do not know about the latest studies. So they might tell patients: you do not have silent reflux – even if they do and would profit from therapy. This gives the disease more time to damage the body.
PPIs Can Still Make Sense – If Used Correctly
Under the right circumstances, PPIs might still make sense.
The point is: studies do not check whether patients have changed their eating habits.
Leading heads in silent reflux research assume the following: if you just take PPIs and have normal eating habits you will still have a high enough acid intake to reactivate the pepsins. That is the mechanism of silent reflux.
Taking PPI will not make a significant difference. Most people only reflux much smaller amounts of acid in their throat than they drink or eat.
However, if you limit your acid consumption AND at the same time take PPIs – that might help.
In other words: PPI together with a strict diet might be more effective than only a diet. However, this is only an assumption.
As it is so important I will say it again: PPI without a significant reduction in acidic consumption will most likely not help against silent reflux. PPIs do not change that pepsins are coming up with your reflux.
PPIs can Increase Reflux Symptoms
It is even possible for PPIs to increase silent reflux symptoms.
The drugs have a negative influence on your digestion.
We need acid for food to be digested quickly. With less acid it takes longer till the food is passed on into the intestines.
If the food stays longer in the stomach due to PPIs, then there is more time for reflux.
Also, the stomach is not a static organ – it moves to mix gastric juice and food. When there is less acid, the stomach might start to pump stronger to mix the small amount of remaining acid into the food. More movement also means there is more reflux spilled up.
PPI are Addictive
If you use PPI for more than a few weeks, the stomach will produce more acid once you stop using the PPI.
This mechanism is called “rebound-effect.” The longer you took the drugs, the stronger and longer lasting this effect will be.
Many people start to develop GERD symptoms after stopping PPIs, due to the rebound effect. The higher acidity levels are too much for the esophagus. To stop those rebound symptoms, people take PPIs again – a vicious circle starts.
Because of the downsides and little upsides of PPIs, leading experts start to treat reflux with specialized diets instead.
PPIs Might Help In Special Cases
Still: there are probably people for whom PPI treatment makes sense: people who really have a silent acid reflux.
Most people have only minor amounts of acid coming up into the throat and airways. But some people have a higher acidity level in their reflux. For them, it might make sense to test PPIs – but we do not have the data yet to prove or disapprove that theory.
Also, it is unclear which amount of acid is too much for our throat.
If we only have some gasses coming up periodically – how much-contained acid is too much? Nobody can tell (yet). Often a pH of 4 is defined in reflux testing as a threshold. However, this is just a random number – that kind of sounds fine.
It Is Important WHEN You Take PPIs
Something that experts agree on: if it is sure that a silent acid reflux is too acidic and one wants to take PPIs – then a two-dose treatment makes sense.
One in the morning before breakfast, one in the evening before dinner.
The reason is: if acid is causing silent reflux problems then it is important to block it for 24 hours. Soon after a dose of PPIs the pH level in the stomach starts to fall again – even if it takes days to get back to the old level. Two doses a day creates a more stable acidity level.
To Sum It Up
PPIs are prescribed WAY more often than they should be as a silent reflux treatment.
Studies show they generally do not work better than placebo for silent reflux. They might make sense in some cases in which the reflux is very acidic, but we lack the scientific data to tell that for sure.
So we always play roulette when choosing to take PPIs or not.
PPIs do not make sense if you do not optimize your diet. Otherwise, you will still have a high intake of acidity from food and beverages.
So changing your eating habits is the key to becoming better.
Note that I am using the term LPR (laryngopharyngeal reflux) instead of silent reflux in the course. LPR is the official medical term for silent reflux, but both mean the same thing.