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

Week 16 Recap: Celiac or Gluten Intolerant?

Well, it’s here! Summer has unofficially arrived in Montana after our usual 7 months of winter followed by 8 hours of spring. We may get hail storms from time to time through the summer, but I don’t expect any more snow until this fall. Yet, you know what they say in Montana, never say never!

On to last week’s recap in my adventures of going gluten free…

I am actually still in the process of determining whether I even have celiac disease or not. We are in the final throes of testing—the genetic screen has been sent to California to determine whether I have the gene for celiac or not. The results should arrive later this week. All other tests and biopsies at this point in time are normal.

My follow-up with the GI specialist went very well. My blood pressure was 102/80 and my pulse was 76. I am not IgA deficient, so that is nice to know. There was no sign of cancer or any disease in my stomach and small intestine—only a small 3 mm hiatal hernia. She recommended that I stop taking Prilosec (omeprazole) in the evenings, and take it only in the mornings, half hour before breakfast. After a month or two, I am to reduce the Prilosec to every other day for a month or two, and then eventually stop taking it altogether. Additionally, the GI specialist also wants me to see a dermatologist for the DH (dermatitis herpetiformis) once the results of the genetic screen for celiac comes in.

ODD THINGS THIS WEEK:

• Some twitching and slight thumping in chest, followed by slight pain to left of sternum as well as left subclavian and achy left arm.
• Very slight fluttering in chest several different times this week
• One morning, while eating my morning yogurt, my tongue started tingling. Not long after, my hands were feeling numb and flushed.
• Late in the week I experienced a painful double heart palpitation which caused me to cough, while sitting on my bed working on my laptop.

My “physical therapy” went very well this past week even though I was not able to spend as much time with Pilates as I normally do. All my treadmill walks (two daily 30-minute walks, 6 days a week) went very well and I did not feel stressed or tired, or pain in any way… pretty much normal walks. Exercise totals for the week include 60 minutes of Pilates, 30 minutes of weight-bearing exercises, and 18.66 miles walked.

Though I can only speculate what my serology results and biopsies would have shown three or four months ago when I first suspected celiac disease, my current lab results are all completely within the normal range for everything.

The following quotes I found in the Winter 2009 edition of the online “Easy Eats” magazine (“Easy Eats: The magazine for gluten-free living”), and thought they were especially pertinent in my particular case:

“Celiac disease patients with lesser degrees of villous atrophy are less likely to have positive celiac serologies” (“Digestive Disturbances and Science,” 2004).

"Recent literature data showed that serology (not only EMA, but also anti-tTG) seems to be ineffective in detecting most patients affected by subclinical/silent disease" -- i.e., gluten sensitivity rather than celiac disease ("Digestive and Liver Disease," 2007).

"If eliminating gluten from your diet results in your body feeling better, that is a positive test" (Dr. Vikki Peterson, DC, CCN, Founder of HealthNOW Medical Center, 2009).

Whatever the case—celiac or gluten intolerant—the treatment remains the same. The next question will be: is gluten intolerance inherited (should my kids be worried)?

Week 14 Recap: Finding "Normal"

This week I found out that our neighborhood has levels of PCE (the nasty carcinogen, tetrachloroethylene) higher than the state allows due to the laundromat leakage in 1989 about a block away, and have been wondering what this means for us... I've always believed this house was making us sick. I drink more water than anyone in this family and I drink it out of the tap. If PCE isn't in the water, is it in the ground? We’ve kept a vegetable garden for years! Our house was not one of the random houses tested, but it would be interesting to know.

Well, back to the recap:

I’m beginning to believe ergocalciferol (prescription dose Vitamin D) might be causing or contributing to what I call occasional “left subclavian” pain— pain that is in the general area below my left shoulder that tends to follow the left subclavian vein/artery. Sure enough, within a day of taking the ergocalciferol, this annoying and random pain was back. The good news is that it is not a long, sustained pain, but something that is just felt off and on throughout the day.

On Wednesday morning I went in for the EGD (esopagogastroduodenoscopy), in which the doctor sent a scope down my esophagus and took a look around. At 8:30 in the morning, I was prepped and ready to go. My blood pressure at the time was 106/72, and I was hooked up to a saline IV solution. By 9:15 I was wheeled into the procedure room full of monitors and equipment.

The nurse told me she was going to inject some medicine into my IV that would make me sleepy, and then told me to lay on my left side. I proceeded to lay on my left and the next thing I remember, I was waking up in a completely different room, the procedure already completed. I was informed that the doctor had tried to talk to me but apparently I was still out cold. It doesn’t take much to knock me out, it just takes a bit to keep me there! I don’t have complete memory of laying on my left side, so I am sure somebody must have been there to catch me. We joked later about the medical staff taking bets to see how long till the patient hits the table.  Somebody could have scored big on me!!

As it turns out, I have a “small hiatal hernia” and biopsies were taken from both the stomach and the duodenum (small intestine). I doubt anything will turn up regarding celiac disease since I have been gluten-free for three months (to the best of my knowledge and abilities).

After the procedure, I felt a bit woozy, but otherwise fine. I tried to sleep off the medication, but in a noisy house full of kids, telephones, and barking dogs, even a medicated sleep was impossible. Oh, how I would have loved to sleep! Once the medication finally did wear off I realized just how sore my throat, stomach, and small intestine actually were! To top it off, I had to deal with this achiness for about two more days, including the continual taste of blood in the back of my throat, and an unpleasant three-day flare-up of acid reflux.

The arrival of the weekend marked my next dose of ergocalciferol, and right on schedule, I felt the first definite heart palpitation I’d felt all week and a double palpitation later in the day. I was also experiencing left subclavian pain again off and on all day, just when the same pain earlier in the week had finally settled down. One other thing I noticed with the ergocalciferol is that for a day or two after taking it, my stomach will feel somewhat glutened and achey. I’ve been having doubts as to whether there isn’t some cross-contamination or small amount of gluten in the pill.

ODD THINGS DURING THE WEEK:

• A headache enough to make me nauseous-- not so much when I sat down but whenever I stood-- both sides of the head.
• Left arm felt slightly numb, and the front of my left shoulder a little achy, and left hand tingling-- on two separate days during the week.
• Tongue began tingling again, late in the week.
• In the wee hours of one morning I woke up enough to feel a heavy trembling in my neck.  I was too groggy to worry and noticed only that it was a very heavy trembling when compared any previous trembling I had felt.  I fell back asleep almost immediately.

Week 14's "physcial therapy" went well.  My treadmill walks seemed easier — no palpitations, congestion, or pain that I noticed.  I totaled 115 minutes with Pilates, 80 minutes with weight-bearing exercises, and walked 16.35 miles. 

In spite of some very minor setbacks with the EGD procedure and possibly with ergocalciferol, it was a good week.