Dr Karine Nohr looks at alternative approaches to help with a common problem – dyspepsia.
Dyspepsia is such a common symptom and PPI’s are probably one of the commonest group of drugs that we prescribe. But are PPI’s as safe as they ought to be, given our current level of prescribing?
The most common PPI side effects are nausea, abdominal pain, constipation, flatulence and diarrhoea. Myopathy, arthralgias, headaches and skin rashes have also been reported.
We’ve had two patients in our practice whose hyponatraemia responded to stopping their PPI. Discontinuation of omeprazole after chronic use may cause a rebound hypersecretion of gastric acid, explaining why some patients find it so difficult to stop taking them.
Additionally, a two-fold increase in Clostridium difficile colitis and an increased risk of Campylobacter, Salmonella gastroenteritis and community-acquired pneumonia has been seen.
Recently we have been warned to avoid the concomitant use of clopidogrel with a PPI because it was found that found that taking the drug along with some PPI’s increased the risk of recurrence of MI.
If this was not enough, PPIs are one of the most frequent causes of drug-induced acute interstitial nephritis (which in some cases leads to renal failure) and can cause malabsorption of calcium, iron and vitamin B12 and are associated with magnesium deficiency. Long-term use appears to predispose people to hip fractures, possibly through the mechanism of reduced calcium absorption.
For conservative management of the dyspeptic patient, how else might we approach this problem?
Using a food log may be a useful way to reflect on the patients’ diet and their symptoms. I have recently started to use these and have been quite impressed by the information that it provides. This is particularly so for the patient, who then faces the reality of their diet (e.g. quite how often they eat rubbish, or overeat, associations with activities or events) and the patient can see for themselves what dietary constituents are problematic for them.
Preparing a proforma that you can just print off your PC, (alternating columns for food eaten, symptoms, activities; 24 hourly rows for time), just takes a minute to explain, and hands the responsibility to the patient for some self-management, which they can bring back to you, completed with their own observations and reflections.
Associations between smoking, alcohol, caffeine and salt have been supported by some studies and refuted by others. Anecdotally, implicated foods include spicy food, onions, peppers, acidic foods, fatty and fried foods. Evidence to support this is surprisingly sketchy.
Herbal approaches to gastro-oesophageal reflux disease (GORD) include deglycyrrhized licorice (DGL), D-Limonene and also demulcents such as marshmallow or slippery elm.
DGL is safe for prolonged use. (ordinary licorice is safe for use for 3-4 weeks but the glycyrrhizic acid component, in long term, use can be associated with hyperaldosteronism). Chewable tablets of DGL can be taken either 30 minutes before a meal or one hour after. DGL can be used to wean people off PPI’s.
D-Limonene is a constituent of citrus peel and can be given at a dose of 1G on alternate days for 10 days (citrus peel is used a lot in traditional Chinese medicine to aid digestion and relieve flatulence).
Demulcents are soothing for sore throats, oesophagitis and gastritis. Marshmallow can be used as a root or a leaf. My adult son suffers from dyspepsia and I have just introduced him to marshmallow tea, with which he is quite impressed.
Slippery elm powder has a nice taste and can be used as a gruel or in powder form or as lozenges.
Another consideration – in some patients dyspepsia may actually be due to hypochlorhydria, rather than hyperacidity. This might explain a lack of response to PPI’s. For these patients, prokinetic agents may be more useful, such as metoclopramide, domperidone or ginger.
Dr Karine Nohr is a GP in Sheffield
Dr Karine Nohr