Dr. Roach: Can you take a PPI forever?

DEAR DR. ROACH: You have written about PPIs such as Prilosec, which I have successfully taken for over 10 years to fight a severe case of GERD with a small hiatal hernia.

However, what is your opinion on my long-term usage (which has been a true lifesaver) and continuing it essentially forever? My gastro specialist seems to be of the “keep taking it” attitude because of its success, but aren’t there potential downsides, specifically to kidney function?  Is switching to an H2 blocker like Pepcid or Tagamet any easier on the kidneys? — K.J.

ANSWER: All medicines have side effects, and it is worthwhile to periodically examine the risks and benefits of taking a medication long term. You already know the benefit: a large improvement in your quality of life. Balanced against that are several potential risks.

The clearest risk is probably infection. Not being able to make stomach acid puts a person at risk for Clostridium difficile infection (severe diarrhea) and other infections, perhaps including pneumonia. Malabsorption of nutrients, especially magnesium and vitamin B12, is so frequent that testing may be appropriate in people who take PPIs long-term. Calcium may also be affected, potentially increasing risk of osteoporosis. This also deserves screening in the appropriate people at risk.

The association between chronic kidney disease and long-term PPI use is controversial, and is probably small. Still, a periodic check of kidney function is wise. There is weak evidence for a small increase in dementia risk.

With all of these risks, my preference for patients on long-term PPI is to try taking them off the medicine slowly and replace it with an H2 blocker, just as you suggest. It is effective for many, but there are some people who really need a daily PPI in order to not have significant daily symptoms. It is up to the person, but the risk of serious side effects is small enough that the benefit outweighs it for most.

DEAR DR. ROACH: After my wife and I receive both shots of the COVID-19 vaccine can we resume our gym classes and return to restaurants? We are both in good health. She is 68 and I am 70. — G.G.

ANSWER: Not immediately. The vaccine is given in two doses, three or four weeks apart, and maximum protection isn’t reached for two weeks or so after the second dose. Even then, the protection isn’t perfect: 94% to 95% according to the best studies for the currently available vaccines. Because there remains rampant transmission in all areas of the country, it is safest for you and your wife to continue to socially distance and wear masks. That’s particularly important for people at high risk of complications.

Secondly, although the vaccine is excellent at reducing risk of developing symptomatic COVID-19 infection, it isn’t clear whether it stops asymptomatic infections. It is possible that vaccinated people may be temporarily infectious after being exposed, without ever knowing they might be spreading virus. Until it is known for sure that is not the case, it is safer for others if you and your wife, and all of us who have been vaccinated, continue to wear masks and socially distance.

Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu or send mail to 628 Virginia Dr., Orlando, FL 32803.

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