Acid reflux drug linked to more than doubled risk of stomach cancer | Hacker News Reader

Acid reflux drug linked to more than doubled risk of stomach cancer

theguardian.com

121 pointsleoh82 comments

>>Responding to the study, Stephen Evans, professor of pharmacoepidemiology at the London School of Hygiene and Tropical Medicine, said: “Many observational studies have found adverse effects associated with PPIs.

>>"The most plausible explanation for the totality of evidence on this is that those who are given PPIs, and especially those who continue on them long-term, tend to be sicker in a variety of ways than those for whom they are not prescribed."

Why is this not at the beginning of the article?

I suppose, the silver lining is that the headlines are no longer "X causes cancer", but "X linked to cancer".

Nothing gives you a morning dose of fear like reading this about a drug you’ve been on for 6 years. Guess I’ll start looking into alternatives and ways to screen for stomach cancer.

FWIW, one of my GI doctors recommended trying alternatives to PPI's, while the other was highly skeptical of these data mining studies and recommended staying the course unless a causal link is established.

It’s so frustrating to often get conflicting advice like this from medical professionals. I understand why it happens but it makes it difficult to make decisions as a patient.

I was on PPI's for a bit. I went on a strict diet and lost about 100lb's which got the disease under control.

Recently I have found CBD's work wonders for helping every aspect of my GI issues. I can't believe how amazing CBD's are. It's no wonder that pharma is working overtime to keep this kind of product out of our hands.

CBD's as in Cannabidiol? If so I can second this for GI issues. Though I usually find that the full spectrum tinctures work much better for regulation of symptoms, even the ones without THC. For reference, I've had Crohns' disease for almost 10 years.

I've been on prilosec close to 15 years. Unfortunately H2 blockers don't seem to work for me. I'm not sure what to do. I can go without it for a month or so, then crippling stomach pain and indigestion happens.

Check for gallstones.

I had that, crippling stomach pain, which was initially diagnosed as either gastritis or possibly an ulcer. However, after dealing with it for a couple years, I ended up in the emergency room. They ran an ultrasound, and found a number of gallstones lodged in the duct that connects the gallbladder to the stomach. Ended up having my gallbladder removed.

Items that I remember triggering massive pain attacks include pizza (I thought it was acid from the tomato sauce, but it was fat from the cheese), and after eating a large gyro (lots of fat in it apparently). Fat causes the gallbladder to start pumping, and if there are stones it will lodge them in the duct causing the pain.

And if you have gallstones, ride a rollercoaster! Specifically Disney World's Magic Kingdom Big Thunder Mountain Railroad. http://www.cnn.com/2016/09/28/health/kidney-stone-roller-coa...

Try reviewing your diet, the times when you eat and drink plenty of water. Mercola's solutions worked for me. 'acid reflux' - https://articles.mercola.com/sites/current.aspx

Please don’t ever recommend the internet quack Mercola to anyone. He will and probably has gotten people killed with the garbage on his site.

No, it was anecdotal! The advice worked for me, it was logical and it solved a problem I'd had for a number of years so it might possibly work for someone else. That is all I said. This was not a generalized recommendation for the work of Mercola. Let people make up their own minds.

I'm aware of Mercola's reputation but it's a bit crass to say that everything he writes is garbage especially since he's usually enthusing about good food and healthy living. Peer-reviewed papers are a few clicks away these days so one can check for oneself on many issues.I don't take the view that his site is popular because the the millions who read him are idiots. I suspect that many do though.

Paradoxically, I cured my reflux with betaine HCL (with pepsin) and digestive enzymes.

I found that when I eat meat and/or when I’m stressed, my body doesn’t naturally produce enough “good” acid. This leads to a build up of reflux because the meat is essentially rotting in my stomach, which creates awful “bad acid” reflux.

Instead of the drug(s), with every meal, I recommend taking one capsule of betaine HCL (with pepsin) and one digestive enzyme capsule.

I would recommend talking to your doctor before accepting medical advice on the internet. Please do not accept medical recommendations from strangers who are not licensed to offer medical advice.

Also, if you continue to have to treat symptoms on a regular basis you did not "cure" anything, cure implies that you are free from managing your symptoms. Rather you are managing symptoms and doing nothing about the cause.

> Rather you are managing symptoms and doing nothing about the cause.

Which is also what a licensed MD does when he/she puts you on a proton pump inhibitor.

Ulcers are one of the possible results of acid reflux, that's a symptom too but also a risk factor. You won't be able to heal ulcers if you don't get the acid reflux under control somehow first.

I'm on Pantoprazole for over a year now and saw my doctor a few weeks ago; I asked about long term risks, and she mentioned stomach cancer, but framed the dangers a bit differently than what I've read in the article from this study.

Basically the established risk is that these PPI drugs work so well that if you were to develop stomach cancer while taking it, the likelihood is strong that the drug would mask the symptoms of the cancer until it was already too late to treat it effectively.

Long story short, I am not (this kind of) scientist, I know it's not a miracle drug but I can testify with anecdata that it certainly does a great job of controlling reflux.

(What my doctor did recommend was of course better diet and exercise habits, not eating so late in the day, and not drinking alcohol right before bed, so I can eventually stop taking it without those symptoms coming back.)

It's quite worrisome for me reading this article now!

>my body doesn’t naturally produce enough “good” acid.

Most acid reflux is due to mechanical action of a sphincter not working correctly. This, if correct, is an edge case.

This is most likely an evolutionary flaw that can't be fixed short of genetic engineering. I also have this my experience is your opposite. Carbs cause excess acid for me and that means my leakage rate is higher. Eating more meats and veg helps a lot. As others have stated, the traditional human diet is relatively low carb, so our modern diets are things our bodies are fairly unequiped to handle (carb crashing, obesity, celiac, etc).

I'm glad you found something that works for you, but most reflux sufferers don't have a "good" vs "bad" acid problem, they have a sphincter problem.

Yeah I assume my sphincter problem is genetic since several family members have it too.

I use a simple mechanical solution - go to sleep on a wedge pillow. Works way better for me than H2 blockers (which would last for 6 hours of sleep, then I'd wake up with horrible reflux because they'd worn off and thanks to the rebound effect, my body was making even more acid to compensate).

By comparison, now if I wake up later in the night now I can usually remove the wedge pillow and go back to sleep with no problem.

> my body doesn’t naturally produce enough “good” acid

Exactly. The amount of people completely, and utterly, misinformed about acid reflux is astounding. You don't have too much acid, you don't have enough!

Ditching the dairy and drastically cutting back on animal flesh will cure most heartburn/acid reflux.

For me it was increasing meat and fat and cutting carbs. Doing that has all but eliminated my reflux until I change my diet for a moderate amount of time.

For me, it's cutting out (or at least, reducing) Pizza... my favorite part of the food pyramid

I had a similar experience. Full keto diet and it's gone completely (it used to be a huge problem). I'm not saying that carbs were the sole cause. I think it was a combination of the carbs and fat and just being overweight in general. Losing weight and sticking to a relatively healthy diet can work wonders for your body.

I started taking a probiotic (cheapest at whole foods) and stopped getting acid reflux all together.

>> Ditching the dairy and drastically cutting back on animal flesh

Sounds like moving to a healthy diet to me...

I think I could actually hear my eyes rolling just now.

Same experience here. Been reflux free for years now and have better GI motility even when I don't take betaine HCl.

For large trigger meals + alcohol (e.g. greasy pizza and beer) I'll still take some.

Changed my life.

Seriously. I've been taking it sporadically for about that long as well. Doing the same as you now.

It's much more likely that those taking such drunks, are at a much higher disposition of developing such complications.

I started taking such a drug again after developing stomach issues. I had a scare a couple of years ago, and it was only by chance that I changed to another GP who was much more attentive, turned out that I was only months away of having a haemorrhage that would have likely been fatal. All from a few years taking a 'safe' anti-inflammatory. Now I won't touch any NSAIDs (which is a shame as I'm in more pain), but it isn't worth the risk of further damage, which was left me as a coeliac (body went after the wrong target).

How often do you read about NSAIDs? No, it's how Fentanyl is killing so many heroin addicts, yet the patches are safely used by millions.

Where's the edit gone? I meant drugs, not drunks (long day).

Everyone will give you advice, but if the issue is simply that the sphincter muscle isn't strong enough, nothing will fix that except surgery. I had this done and it has been life changing: www.livingwithreflux.org/nissens-fundoplication/

I can't find it but I once read that acid reflux was actually due to not enough acid, as what you were ...refluxing was partially digested foods. You might try taking an acidifier and see if that helps.

Have you tried probiotics and/or walking for 10-15 minutes after eating? I get the occasional GERD but nothing if I do both of those things afterwards.

Have you tried an H2 blocker, such as famotidine?

They are also fairly strongly linked to Alzheimer's.

People don't realize PPIs are a short term solution. PPIs are terrible long term. That being said, I'd be long dead without them. They are truly a life saver until you find out the root cause. Many trips to the ER and years later, I found out avoiding gluten and taking probiotics cured mine.

Some people (like myself) suffer from functional dyspepsia, in which GERD-like symptoms are observed with no apparent cause. There's really no standard treatment: some people find relief from PPI's, H2 blockers, small doses of SSRI antidepressants, or changes in diet. Every doctor I've talked to (including one of the top gastric neurologists in the country) agrees that, given a choice between taking PPI's long-term or suffering from functional dyspepsia, they'd take the former every time.

References:

https://www.ncbi.nlm.nih.gov/pubmed/28271513 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4070655/

Indeed, I was on PPIs for years. Before them, I used to wake up choking on bile, I was eating tums like candy. Then I changed my diet and starting taking baking soda in water of all things. When travelling I'll go back on PPIs for the trip, and notice a distinct feeling of unwellness. But I simply don't want to deal with questions of the form; 'what's this white powder in your luggage?' so I deal with it.

I've had to make my peace with just having to hit a store on the other side of the trip. Fortunately, baking soda is cheap enough that you don't have to mind throwing it away.

You could also conceivably make your own pills, which at least in my experience nobody will question: https://www.amazon.com/Cap-M-Quik-Tamper-Capsule-Filling-Mac... (I don't make my own pills, but I've carried around a variety of pills that look like they were made that way.) But for baking soda that's probably a little elaborate, plus I don't know what happens if you take baking soda that way rather than in water.

Same story here. Aspirating bile is the worst, that awful soap taste, the burning when breathing.

For me, cutting gluten and fried foods out of my diet entirely minimized my stomach woes. The gluten thing came about after I was tested for antibodies when my son was diagnosed with type 1 diabetes. So, lucky, not lucky I guess.

"I found out avoiding gluten and taking probiotics cured mine."

I've done keto and it worked for me, could have been the elimination of gluten in retrospect. Haven't tried the probiotics.

A couple of months into my low carb diet, I realized I hadn't taken any (because I would only take them when I felt symptoms).

Hacker News continues to amaze. There's always a worrying high ratio of comments in health and diet threads from people making drastic and impulsive decisions without medical advice, usually off the back of incomplete conclusions or anecdote.

Newspaper coverage certainly needs to contain more scrutiny of the quality of scientific papers (and their review), but this paper explicitly concludes that there are other factors at work.

Don't stop taking your meds. If you have reflux issues and you're concerned about this, take the paper to your specialist and get their informed opinion.

Notably, this isn't the first study to raise an uncertain, correlation risk about PPIs. A specialist, or in many cases even a GP, should be aware of the topic and able to answer questions.

I'm also a bit disturbed to see people framing this as "comfort versus cancer" - seeing as untreated acid reflux can be a cause of esophageal cancer, "I'll just quit without asking a doctor" is far from a sound course of action.

I wish there was more info out there on the risks for reflux -> Barret’s -> cancer. I could barely find anything when I last looked, except that frequent reflux sufferers are advised to get an endoscopy once every few years. (So I guess Barret's develops pretty slowly?) Also, the fact that smoking is correlated with both reflux and cancer significantly confounds the issue.

I think LPR and GERD are kind of unique in that their symptoms are all over the place and long-term solutions are very hard to come by. In many cases the meds only mask the condition instead of fixing it, and doctors often don’t know what to do except recommend lifestyle changes and prescribe more PPIs. All the while endoscopies etc. come back clean and you still feel like crap. It’s a very mentally taxing group of disorders!

Quite a commentary on the lack of confidence in modern medicine isn't it? No none trusts the specialist.

Why almost no journalist ever links to the actual research papers, or, at least, properly name the authors and the paper title? Is it that hard to put a DOI in a small font somewhere? (Or am I just blind?)

Yeah, I had to try to find it myself as well. I believe this is the one:

http://gut.bmj.com/content/early/2017/09/18/gutjnl-2017-3146...

Thanks, I came to the HN comments to see if someone posted the link to the study.

Damn! And if you don't treat your acid reflux, it can cause "esophageal cancer".

Maybe growing numbers of "damned if you do, damned if you don't" situations are the natural result our current 'late stage' medicine.

An analogy that came to mind: an enormous, largely opaque codebase that works very well. Most of its behaviours given most inputs are well understood, most of the time, and endless optimizations have caused it to reach a pretty good level of stability.

But maybe, going forward, more and more small optimizations and bug fixes cause as many problems as they fix.

Clearly we need to re-factor ourselves. (:

It worries me when I read an article like this, then see people in the comments suggesting that they're stopping their PPI prescription. Which ironically might increase their chance of cancer, depending on the indication.

Even at the end of the article the authors conclude:

> “The most plausible explanation for the totality of evidence on this is that those who are given PPIs, and especially those who continue on them long-term, tend to be sicker in a variety of ways than those for whom they are not prescribed.”

That's because this is an observational study. That means there is probably another confounding factor that is perpetuating the use of a PPI in some people, but not in others. Sometimes these confounding factors are controllable - as long as you know what they are - but usually they are not. For example, those who were taking omprezole may have peptic ulcer disease - which would put you at risk of gastric cancer, and for which the PPI is used to reduce the acidity of the stomach, and reduce the risk of ulcers and inflammation (which can be a precursor or risk factor for cancer). Similar story for gastro oesophageal reflux disease, where the risk is to the oesophagus.

If you want to answer the question 'Does taking a PPI increase my risk of gastric cancer?' you need another type of study. That is a randomised controlled trial, where you randomise people to either the PPI tablet, or a placebo, then measure what happens. This allows you to infer causality, and the randomisation prevents confounding factors.

Thankfully this has been done[1]. It's only one paper from a low-impact journal, but none-the-less a meta-analysis of several RCTs setting out to answer a specific question holds more weight than an observational study.

Also, I'm not a gastroenterologist, so if there is one out there who understands the field better, please chime in. Specifically, if you have a clear medical reason to be taking a PPI (i.e. reflux with oesophageal histology changes), are there RCTs comparing PPI use versus not? I've done a quick google and this [2] study seems relevant - they suggest that if you have mild disease you can just take the PPI when you have symptoms, but not for severe disease. However, they didn't assess cancer risk.

[1] https://www.ncbi.nlm.nih.gov/pubmed/23906249

[2] http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2036.2007....

Not to mention cognitive impairment: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4696341/

That study is from 2015. Newer study from 2017: https://www.ncbi.nlm.nih.gov/pubmed/28590010

Jesus.... why isn't that being talked about more.

I got off acid reflux drugs because of the cancer risk by taking a probiotic, which took about a month to have the same effect.

Next week, we will find out the probiotics cause cancer and mental impairment.

and aspirin is apparently good to prevent those. Yet, it'll tear a hole in your stomach... sigh...

http://www.telegraph.co.uk/science/2017/10/30/aspirin-day-ke...

>Daily use of PPIs was associated with a risk of developing the illness that was more than four times higher (4.55) than those who used it weekly.

(IANAD) from what i read on the pill boxes, PPI are supposed to be used max 2 weeks in 4 month period. If you look at the micrograph photo at https://en.wikipedia.org/wiki/Proton-pump_inhibitor showing cell hyperplasia (possible precursor to cancer) resulting from PPI use you'd get the idea. (note: myself use PPI 2 weeks in 4 months (and they do have noticeable lasting effect for long after the 2 weeks course due to nature of their action), and the rest of the time H2 blockers. I limit the PPI exactly because scared by that hyperplasia photo (and now that i read the other comment about cognitive impairment i'm scared even more :). Again - all that is "self-prescribed"/"internet researched", IANAD.

Just to cast the exact same finding in a different way, this appears to raise the incidence rate of stomach cancer from 0.8% to 1.6%.

So where do these numbers come from? Who was in the study and where was it done?

my numbers are overall cofirmed incidence rates. CDC has them.

As someone who as been taking these for 3+ years and is utterly scared of these news I would just like to add a few data points regarding my experience that might help others:

- an endoscopy revealed level 1 oseophagitis

- triggers for me include: coffee, tea or any other source of caffeine, fried and high fat foods, alcohol, acidic fruits, high protein foods.

- an experiment with betaine HCL + pepsin was very painful. After that I learned that pepsin is as bad or worse to your oesophagus than stomach acid.

- cider vinegar: same result as betaine HCL + pepsin.

- digestive enzymes: no change.

- pro-biotics, including kefir: no change.

- cutting gluten, dairy and sugar: no change.

- ranitidine: works but effectiveness drops rapidly.

- on-going experiments: liquorice and low-fodmap diet, no conclusions yet.

went through almost all of your points actually. though my symptoms were "gastro-attacks" of frightening intensity where i'd end up in hospital. ended up having gallbladder removed after test showed it very-low functioning and had complete recovery. took PPI's still intermittently, but tapered off after a couple years.

very very anecdotally I've found that going keto(ish - I didnt go full keto) helped quite a bit.

50 million prescriptions "per year" in the UK? There are only 65 million people in the UK. How do they count this? Is every PersonMonth counted as a prescription? What if you get your refills quarterly instead of monthly?

PPIs are also linked to 50% higher death rate:

https://medicine.wustl.edu/news/popular-heartburn-drugs-link...

Ironic. A friend of mine was prescribed PPI to help prevent esophageal cancer.

Constant reflux does tend to cause esophageal cancer as well as other issues related to breathing and swallowing.

I mostly suppress my reflux through a twice daily regimen of cider vinegar (diluted* ), more walking, eating more conscientiously, and forcing myself to sleep on my left side.

These are all very minor changes, and the biggest impact came from sleeping on my side.

My gastroenterologist was very against the daily PPI my primary put me on. There are a lot of potential negatives there.

* Straight up cider vinegar is very acidic and can irritate or damage the throat and mouth. I drink 1/2 tbsp in a glass of water.

I was on PPIs for reflux for about 6 years before realizing how damaging they could be. Getting off them was really difficult but your suggestions here, in addition to some ginger supplements, helped me to ween off them. Getting off them was a terrible experience, but I'm much better off because of it. I rarely experience reflux anymore.

For a couple of years, the only thing that worked for me was mega-huge doses of PPI's. After several pH studies, endoscopies, and other tests confirmed that I don't have abnormal reflux, food allergies, gluten sensitivity, or anything else, my doctor(s) and I found after years of trial-and-error that a combination of H2 blockers and a low-dose of antidepressants mostly controls my symptoms, which are probably caused by an overly-sensitive gastric nervous system.

In the article it says up to 8 fold increase in stomach cancer for 3+ years, that is insanely significant and for those taking it for 1+ years it's 4-fold.

I was prescribed this for long term use because mine is especially bad but I was too lazy to follow through and felt embarrassed asking for it again so I just eliminated some trigger foods and followed doctors advice on posture and letting food digests for an hour before lying down. It made a huge difference

After having every member of my family get cancer except me I have extensively studied and found proven ways to prevent cancer based on long term studies. I also serve as a patient advocate helping people battle their cancers. In addition I have had gastrointestinal and digestive issues in the past and after lots of doctors, tests, treatments, etc. here are the things that I have found to have worked:

Cancer Prevention (All Types Including Gastric/Stomach Cancer): 1) Don't smoke 2) Eat a plant based (vegan) diet consisting of mostly fresh raw vegetables (raw foods contain natural digestive enzymes which help digest food better as well as being packed with cancer fighting nutrients) 3) Eliminate processed, fried, additive-laden foods 4) Avoid exposure to chemicals, toxins and other environmental contaminants that are known carcinogens. 5) Get plenty of sleep every night to strengthen the immune system. 6) Get a minimum of 150 minutes of cardiovascular exercise each week (more is even more effective) 7) Minimize daily stress to the greatest extent possible (stress wreaks havoc on the body and seriously damages immune function). 8) Drink plenty of water every day.

To Improve Digestive Health/Minimize Acid Reflux & Other GI Health Problems: 1) Eat more raw vegetables which have naturally occurring digestive enzymes (cooking destroys most of these). 2) Eat slowly and chew your food thoroughly. Digestion starts in the mouth with saliva. 3) Don't drink water or other fluids during and for at least 3-4 hours after meals which will dilute stomach acid & negatively impact digestion and break down of food. 4) Eat raw fermented foods with naturally occurring prebiotics & probiotics such as kombucha tea, raw apple cider vinegar (1 tablespoon on food at each meal 3X per day), etc. Studies have shown that pre/probiotic supplements are not effective, only natural foods work. 5) Try and eat smaller, more frequent meals. Large meals are harder to digest & make it hard for the stomach to fully clear food that is eaten which can increase acid reflux/GERD. 6) Avoid bad oils and fats and stick to good fats virgin coconut oil, olive oil, nuts, seeds, avocados, etc. http://drcate.com/list-of-good-fats-and-oils-versus-bad/ 7) Eat more high fiber foods.

These are some suggestions based on many years of research and what I have found to work the best. I'm happy to answer any questions.

I have been using on Prilosec and Nexium since 2000. If I miss taking the medication I get severe stomach pains by late evening. In the last endoscopy the doctor noticed several polyps in my stomach. He said polyps are normal for someone who has been using Prilosec and Nexium for so long. Is stomach polyps a precursor to cancer?

After being on Prilosec for 2 years, I had an endoscopy and the pictures of the inside of my stomach were odd. Little bumps over the entire inside. I asked the doc and he said "we don't think those are a problem". Right. I got off it immediately.

He had a point, though: PPIs are known with very high certainty to cause benign polyps from the fundic glands. Even if they do cause cancer, it's not by that means.

Whether or not they're a good drug to be taking long-term, I think the doctor's response was sound.

The same PPIs were linked to dementia in a study a few years ago, and I began to transition off at that time. I eat a lot of Tums and generally just try to be more mindful of what I eat. I'm also considering surgery at some point.

I switched from protonix (a PPI) after 6 years of constant use to Pepcid (an H2 blocker). Rebound reflux is real and I had to wean myself off the PPI gradually. Now, I take 40mg of Pepcid daily and Tums as needed.

Usually I'm allright if I avoid trigger foods (anything high in saturated fat, excessive sugar, onions, etc.). For some reason I can handle drinking coffee but black tea triggers my reflux like nothing else.

> "In the UK, there are more than 50m prescriptions for PPIs every year..."

I can't believe this. There are only 65MM poeople in the UK, so 50 million would exceed the adult population.

Maybe repeat prescription for the same patient are counted.

Check for gluten intolerance or just follow gluten free diet without any omez tablets for a month. You will never ever get Acid reflux.

I am free of Omez and Acid reflux for the past 6 months.

I am absolutely not surprised that people who are more at risk of stomach cancer... get stomach cancer. Notice how the study found no causal link. Indeed, the last paragraph in the article confirms that it’s probably because the people who are prescribed PPIs are already sick. (Side note: I’m one of those people who’s probably on them for life unless I want to die horribly of esophageal cancer like my father did.)

Reply on news.ycombinator.com