Omeprazole (Prilosec) Withdrawal

Writing often helps me to sort out my thoughts.  It has been that way for my entire life.  If I want to figure something out, all I need to do is start writing.  And true to form, while writing my weekly recap it suddenly occurred to me that the strange stomach aches and trembling I had been feeling for the past couple of weeks might be connected to my cutting back on Prilosec, as per doctor's orders.

I checked back in my Food/Symptom journal and sure enough, the trembling began within a few days of cutting my daily Prilosec dosage in half, from 40 mg/day, to 20 mg/day.  The last time I experienced trembling of the same sort was when I stopped taking clonazepam.  The trembling lasted about a couple weeks.  Could it be that my body simply "withdraws" from chemicals in this bizarre way?  Could a simple, over-the-counter drug have this kind of effect on the body?  I had to check it out.

Doing the usual internet search (Google), I was amazed to find so much information available about Prilosec withdrawal.  Why hadn't anyone warned me that it was possible and what I might expect?

According to many websites, the side effects for medications are also the side effects of withdrawal.  The particular Prilosec I have been taking is omeprazole, delayed-release capsules.  Prilosec is a proton-pump-inhibitor (PPI).

So what is a Proton Pump Inhibitor (PPI)?  Without getting into too much detail, the stomach produces acid (mainly hydrochloric acid) in order to break down our food so it can be digested.  This acid is released through proton pumps which allow the chemical to pass into the stomach.  Sometimes the stomach produces too much acid, which may spill into the esophagus and cause heart burn or acid reflux. The proton pump inhibitor (PPI) is supposed to inhibit the body's ability to produce stomach acid.

Omeprazole (brand name Prilosec) "blocks the final step of acid production.... Animal studies indicate that after rapid disappearance from plasma, omeprazole can be found within the gastric mucosa for a day or more" (i.e., the effects linger on) (PharmaInfo).

According to the July 1, 2009 edition of Family Practice News, after 8 weeks on a PPI, patients ended up with rebound heartburn, acid regurgitation, and dyspepsia (upset stomach or indigestion).  The article "PPI Withdrawal Triggers Acid Hypersecretion" by Mary Ann Moon points out that "Rebound symptoms were clinically significant in the study subjects, causing mild to moderate discomfort for at least 2 weeks after withdrawal of daily PPI therapy--a 'remarkable' finding given that 40% of the study subjects had never experienced such symptoms before, wrote Dr. Reimer of the department of medical gastroenterology at Copenhagen University and her associates."


Symptoms of PPI withdrawal may include:

• Rebound acid hypersecretion within two weeks of withdrawal
• Heartburn
• Acid reguritation
• Dyspepsia

Interestingly, the study (double-blind, placebo-controlled design, including blinded withdrawal of PPI) found that "greater than 40% of healthy volunteers who have never been bothered by heartburn, acid regurgitation, or dyspepsia, develop such symptoms in the weeks after cessation of PPI" (Gastroenterology, boldface added). 

I am not the only one to believe PPIs are greatly over-prescribed.  I have seen it in my friends, and I have seen it in my own family:  Feeling a little indigestion?  Let's put you on a PPI and dismiss it as that.  As what??  My daughter was seen for an "nervous stomach" by a doctor while she was attending college.  The doctor said "You must have a hiatal hernia" and prescribed Prilosec, and never saw her again.  That was three years ago!  She has been on Prilosec ever since, never knowing whether she actually had a hiatal hernia or not.  When she stopped the Prilosec (expensive on a young adult's budget), she developed all the symptoms of withdrawal. 

The internet abounds with forums and patient discussion groups regarding PPIs.  Perusing a handful of these websites, I found some patient-oriented information with regard to PPI withdrawal:

• Taper off slowly to reduce stomach pain and hypersecretion of stomach acid
• Take Rolaids Antacid tablets as needed during withdrawal
• pH levels may be out of whack
• Food allergies and sensitivities may crop up
• May experience loss of appetite
• Trembling, shaking, "buzz"
• Troubles with Vitamin D and calcium defiencies to the extent of severe bone density problems
• Risk factor for Clostridium difficile -associated diarrhea

Incidentally, it is a known fact that "long-term use of proton pump inhibitors increases the risk of hip fractures in adults over 50" (Ray Sahelian, MD, "Proton Pump Inhibitor Drug benefit and side effects, safety, danger and risk").

I'm not saying all doctors over-prescribe medications, but I do think that both sides of the equation carry some blame.  Most patients (particularly American patients) want a quick fix.  If they don't feel well, they go to the doctor and get something for it.  In an attempt to avoid expensive tests and follow-ups, many doctors will give the patient what he or she asks: a quick fix.  There are many more factors and sides to this ideology, but that is not my purpose in writing today.

I do have to say that I think there is a big gap between the pharmaceutical industry and patient knowledge.  Somewhere between those two points lies a gap that needs to be addressed and filled.  The pharmaceutical industry is getting far ahead of the medical industry and governing the direction which doctors should take. Shouldn't the medical industry govern the pharmaceutical industry, rather than the other way around?  Just my two-cents...

Recommended Further Reading:
http://download.journals.elsevierhealth.com/pdfs/journals/0016-5085/PIIS001650850900780X.pdf
http://www.ncbi.nlm.nih.gov/pubmed/19362552

Diagnosis Confirmed!

My first visit with the internal medicine specialist was a little stressful for me, but one of relief, as well.  It was stressful because I didn't really know where to begin.  I was having so many symptoms and they seemed to cross multiple systems in the body.  But it was also one with relief because for the first time in thirteen weeks, the doctor looked at me like he was genuinely interested in what was going on, and just as curious as myself as to the cause!

We discussed several things that were happening-- from the rapid pulse at random (it was 114 in his office at the time), the drug reactions (which I had never had prior to all of this), to the fatigue, the heart palpitations, and even the rashes on both my arms.

The best part about the visit was that there was an answer that would explain several (if not most) of the symptoms: Celiac Disease.  But how could I have CD with the blood tests coming back normal?  His answer was that I had Dermatitis Herpetiformis (DH) and that in order for the blood tests to be positive for CD, I would have had to be on a high (very high) gluten diet for 2 to 6 weeks!  And each time I was tested, I had either been off gluten for a while, or on a very low gluten diet.  The DH was definitive enough, and he told me that experts do not recommend a small intestine biopsy as long as that rash is present.

My DH had been present for 5 years, and nothing (and I do mean nothing!) could make it go away-- whether it was OTC medications, or prescribed.  It will take some time to heal, but it is gradually softening and diminishing.

The internist did order other tests, including more thyroid tests, a 24-hour UA, a DEXA scan (for bone density), a Holter Monitor, and a stress-echocardiogram to find out more about why my heart might feel so weak, or have palpitations.  He also suggested I continue my vitamin supplements, particularly D3, K, Iron, and Calcium/Magnesium.

In the meantime, I joined a couple of online support groups for CD and found an immense number of similarities in symptom stories, particularly with heart palpitations, weakness, and fatigue.  It seems as though the medical community does not have any direct answers regarding the connection between the heart and CD, but keep in mind that CD is a cross-system disorder and can affect any system in the body in a number of ways.  Perhaps the medical community just doesn't want to say one way or the other... playing it safe in their eyes, but not so for the CD community.

My thyroid tests ended up being normal, and at this point I don't know the results of the 24-Hour UA, the DEXA scan, nor the Holter Monitor results (which I wore for 48 hours).  During my time wearing the monitor, the palpitations were mostly quiet or so faint I couldn't be sure it was what I was feeling, so I guess it will be up to the experts to decide.

Happily, my stress-echocardiogram showed "one beautiful-looking pump" (cardiologist's words) with nothing wrong, whatsoever, that he could see.  My blood pressure was great (108/78), my cholesterol was great (162), and there was no visible reason to suspect anything wrong with my heart.  Though it did make me feel better, it does not take away the nervousness when something feels weird with my heart.  Perhaps it is my body's way of dealing with such a vital organ.  I can handle anything with any other part of my body, but my brain does not like it when my heart doesn't feel normal.

At the least, I can say that my heart seems to have settled down a bit and is in a mostly quiet mode these past few days.  Let's hope it continues.