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

Laryngopharnygeal Reflux (Silent Reflux)

I learned something new yesterday from one of the celiac support groups of which I am a member. There is something called Silent Reflux!

For several days, I had been experiencing something like acid reflux, but it seemed to get stuck inside my throat. It was a very uncomfortable feeling and made my glands and voice box feel swollen.

 I did a little research and came across a website at the MidWest Ear, Nose & Throat P.A. (MWEN&T) which names the problem as Laryngopharyngeal Reflux (LPR) and describes some of the symptoms as:

• Hoarseness
• A "lump" in the throat
• Trouble swallowing
• Chronic cough
• Too much throat mucus
• Heartburn

Here is how it happens:  For people who don't have this problem, the food they eat goes into the stomach where digestion begins and that is the end of the story. For those who do suffer from reflux, some of the food comes back up again. In LPR (Silent Reflux), not only do the stomach contents back up into the esophagus, that backflow (food and/or stomach acid) goes all the way back up “into the larynx (the voice box) or the pharynx (the throat)” (MWEN&T). It can happen at any time, even when no food has been ingested, which explains a lot for me. I couldn't figure out why-- if I hadn't eaten anything-- I was still having this problem!!

 Also, when I was originally diagnosed with GERD back in late October 2009 with my first couple visits to the ER, I couldn’t understand how it could be GERD because I had never been one to have acid reflux (at least as I understood it) and rarely had heartburn. And suddenly, these medical professionals were telling me I was experiencing acid reflux but it didn’t feel like any acid reflux!

I couldn't understand it. So I followed all the guidelines for GERD (no acidic foods, no laying down after eating for several hours, no drinking caffeinated beverages, avoided fatty and fried foods, sugary foods, chocolate) -- and it seemed to make no difference what I ate, or what time of day I ate.

According to the MidWest EN&T, “many people with LPR never have heartburn” (italics added) and because it is so “silent,” it can be difficult to diagnose. For people who have had it in the past without realizing it, we don’t feel the heartburn because the “acid does not have enough time to irritate the esophagus and cause heartburn” (MWEN&T).

On the other hand, if that backflow does end up all the way into the throat, apparently even more damage can be done because the throat and voice box are very sensitive to stomach acid and can even injure your lungs and cause difficulty breathing.  Damage can occur not only to the larynx but to the trachea, bronchi, and lungs (hmmm…. thinking chronic bronchitis, here).

“The lack of GERD symptoms can mean that silent reflux damage is quite advanced when it is finally diagnosed. Long-term silent reflux damage increases the risk of acid reflux complications” (Michael McGrath, “Silent Reflux, Esophageal Reflux and Symptoms") .

Many times over the years, I have had difficulty clearing my throat, and my voice was often hoarse, particularly if I had to lay down (whether on the table at the doctor’s office, the dental chair, or anywhere). MidWest EN&T also suggests that some people “have a problem with too much nose and throat drainage, that is, too much mucus or phlegm.” And yet another sign is a post-nasal drip (which I suddenly developed out of no where with no sign of sneezing or sinus trouble).

Did you know that studies "demonstrate that LPR patients are more likely to have reflux in an upright position whereas GERD patients are more likely to reflux in a supine position" (Postma and Halum, “Laryngeal and Pharyngeal complications of gastroesophageal reflux disease” GI Motility Online)? This might explain why I would experience this silent reflux while sitting up, watching TV or typing away on my computer.

Did you also know that it takes longer to treat and resolve LPR than GERD ?  LPR can take several months to heal, while GERD symptoms can improve rapidly (Postma and Halum). The bad news is that people with silent reflux have a greater chance of esophageal dysplasia (cellular changes in the esophagus) and cancer than those with regular GERD (for cancer to develop as a result of LPR, the LPR must be very severe and go untreated for many years. Source: MWEN&T). As well, esophageal damage by acid and pepsin exposure can be reversible, while your voice box and throat can be easily and irreversibly damaged (Postma and Halum).

Did you also know that symptoms of LPR can also include chest pain (McGrath)? Yep, have had that in my little line-up of symptoms, but I'm not saying that is the cause. According to McGrath, “Hoarseness is most common in the mornings, as lying down increases the chances of esophageal reflux.” I’ve had plenty of experience with that. McGrath also states that “if stomach acid reaches the salivary glands, the glands may flood the mouth with a sour, salty liquid called water brash.” Again, another new experience during my 4-day silent reflux also. I couldn’t figure out why my mouth was watering at weird random times.

Did you know that LPR and GERD are not treated in the same way? They need to be treated differently because the laryngeal mucosa is so much more easily damaged than esophageal mucosa. Postma and Halum say that “the esophagus can tolerate exposure of up to 50 episodes of reflux a day without injury” and that “as few as three isolated episodes of laryngeal acid/pepsin exposure per week have been shown to induce injury.” In a nutshell, GERD is easier to treat and responds to treatment, but successful treatment of LPR requires chronic therapy.

That might explain why the clinic orginally had me on the Prilosec (omeprazole, a PPI or proton-pump-inhibitor) twice a day rather than once daily (more commonly for GERD). For LPR, you would need “twice daily PPI coverage” and would need to take it 30 – 45 minutes before breakfast, and again before dinner.

I actually had stopped taking the Prilosec once I finally got the official diagnosis of celiac disease because it didn’t seem to matter whether I took it or not. However, I also found out later that I was not taking it properly (on an empty stomach, at least 30 minutes before eating). It wasn’t until recently that I felt the silent reflux (LPR) again and this time it lasted for several days. But at the time, I didn’t even know it was silent reflux—I just thought it was “reflux” and couldn’t figure out what the heck it was doing in my neck and getting stuck in my throat!!

Just for the record, I am not a pill person. Taking vitamins is bad enough, but at least I know they are all natural, and have no fillers or extra chemicals. Whereas, these medications—I would just as soon do without. Yet, according to Postma and Halen, I need to stay on it for at least 6 months, and if the inflammation is gone I can taper off and eventually discontinue the antireflux meds. According to Postma and Halen, “50% of LPR patients on twice-daily PPI therapy have symptomatic improvement at 2 months, and an additional 22% improve from 2 to 4 months after initiating therapy.”

Other treatments may be as simple as basic antacids like Mylanta and Maalox. MidWestEN&T recommend 1 tablespoon four times a day—basically, one after each meal and one before bedtime. In case you haven’t already noticed with my own personal story (and according MWEN&T), when you have LPR, changing habits and diets don’t always work. So stick to treatment.

What is the connection with celiac disease? According to Postma and Halum, “immunocompromised patients may mount little response with infectious laryngitis” and as such are more susceptible to infections. More chronic forms of LPR can be found in those with autoimmune diseases: “autoimmune diseases that produce laryngeal inflammation most commonly have coexistent systemic symptoms” (i.e. people with an autoimmune disease uaully have symptoms that affect multiple organs, systems, etc.) and if not treated properly, there is a greater rate of reoccurrence and complications.

According to Natural-Reflux-Cure.com, “digestive juices can get into the upper throat at night as with regular acid reflux or GERD, but more people with LPR have damage occur during the day than at night” --which explains my daytime symptoms completely.

The Natural-Reflux-Cure website lists the following as common possible symptoms of LPR:

• Asthma or asthma-like symptoms
• Bad breath that won’t go away
• Belching or burping
• Chronic Cough
• Difficulty singing or extended talking
• Dysphonia (changes with the voice)
• Ear pain
• Feeling of a lump or something stuck in the throat
• Hoarseness
• Laryngospasm (feeling like one can’t catch one’s breath)
• Post nasal drip
• Sore throat
• Throat clearing
• Trouble swallowing
• Weak voice
• Wheezing

So, how is your LPR or Silent Reflux? Are you minor, major, or life-threatening? If it is just an annoyance, than it is minor (like mine). If it is major, than your symptoms interfere with your social life and/or with work. Certainly, if it is life-threatening, then you have an “airway obstruction problem, severe pulmonary disease, or malignancy” (Postma and Halum).

How do they diagnose LPR? A throat exam is the first step in the diagnosis because your throat will likely look red and swollen. A couple nights ago, for example, my voice box felt so swollen I had to breathe through my mouth a few times, or scoot my jaw foreward (which I find myself doing a lot anyway because my jaw seems set too far back-- at least that was my reasoning for breathing better, anyway).

Tests for LPR include pH monitoring (or pH-metry) and a barium swallow in which you swallow a chalky liquid that can be seen on x-rays. It will reveal any narrowing or abnormalities in the throat or esophagus (MWEN&T). The pH-metry involves a 24-hour, over-night test (done at home) in which a tube is placed through your nose and stays in your throat to measure acid.

And believe it or not, LPR can occur in babies and children! It can cause throat and lung problems and even breathing problems in babies who seem to have a lot of phlegm of difficulty swallowing or nursing. I would have never guessed a baby could have acid reflux!

Personal conclusion: Sometimes I wonder if this is why I could never yell (my yells end in fits of coughing) or speak loudly (why I am always so ‘quiet’) or read aloud for long periods of time—my voice becomes weak and hoarse and I begin coughing or just lose my voice. When I was younger, doctors would just dismiss it and say “Oh, its probably just scar tissue from repeated bouts of strep throat.” I’m beginning to think I’ve had this LPR off and on, all my life.