How to Manage PPIs

Overview

The framework for patient individualization is always important, and we all need to be reminded of this as we discuss and affirm one another, sharing our struggles together. From the Five R Program (helping our patients understand that there’s a strategy and a step-by-step process) to problems with Proton Pump Inhibitors (PPIs) (weaning people off PPIs so they can absorb nutrients), our collective discussion helps us see that we are all on this journey together.

Blog Introduction

Hello, my name is Dr. Cheryl Burdette, and I am the Director of the Clinical Curriculum for Origins Incubator. This week, we talked about the Five R Program, and we talked about, “Is this something that we want to do sequentially?” or “How do we approach this with our patient population?” And in that discussion, we looked at how the various Rs in terms of remove would also help with the repair and there in the repair also helps with the re-inoculate. We concluded that this is a framework to help our patients understand that there's a strategy, and there's a next step, and it's not really something to lock the clinician into doing "X" first and "X" next because we always want to be able to individualize. Our work is not a cookie-cutter formula.

Proton Pump Inhibitors (PPIs)

Within the scope of that conversation was also the topic of PPIs and what do we do when we are faced with this. We will have these patients on PPIs, who are horribly nutritionally deficient because they've been on them way longer than they should. Then, as soon as we try to get them off, they have distress from that. And so, one of the things about the discussion was just affirming every time we get to hang out with colleagues and have these conversations, understanding that this is something that's not simple for any of us and that we've all struggled with it, and you know, “sounds so simple… just transition somebody off their PPI and their nutrients will go up.” Well, that's not really the way it plays out. So, we received the affirmation of understanding that we all struggle in this area. 

Why do we struggle?

There are two reasons for our struggles. The first is that when we are on PPIs, of course, we make less hydrochloric acid, and that's the whole point of it. The research is very clear that when that's the case, we leave larger proteins intact, and those things will atrophy the gut lining. The longer you're on them, the more you wear down the gut lining, but it's not the only way they do that. And in fact, if we go to PubMed, there is a huge body of research that talks about PPIs and atrophying the gut lining because the second way they do that is they inhibit the breakdown of asymmetric dimethylarginine (ADMA). And when there's higher levels of ADMA, it inhibits our production of nitric oxide. Well, we need nitric oxide to have good blood flow to the gut. In fact, if we look at the area where there's a large study right now, a large focus in terms of Crohn's Disease, one of the drugs that they're working on developing is things that increase nitric oxide to the gastric lining. So, it's even got a focus in terms of a whole strategy for treatment of things like irritable bowel disease. 

What happens when on PPIs?

So again, here we are, we're on these PPIs. The first thing that happens when we get on them is our cells in the stomach say, “No, we need hydrochloric acid.” We up regulate the number of cells. And now, if somebody tries to immediately come off a PPI, they have more cells making hydrochloric acid than before. Their initial response or feeling is “This hurts even more than it did before I got on these; I must really need them.” At this point, it can be very difficult then to convince or help a patient to realize, “No, they are inhibiting nutrients and there are things that we need to work on in order to get you back in place.” As you can see, that is worse. If you just tried to put them all together, you're producing more hydrochloric acid than you were. So, of course, it hurts even more. The second thing is now you've atrophied your gut lining for a couple reasons: proteins have irritated it more and you're getting less blood flow. 

Getting People Off PPIs

We went through a stepwise discussion of how we get people off PPIs. We talked about introducing demulcents first and how you want to go about that, we talked about the deglycerized licorice and things like melatonin that increased tone of the lower esophageal sphincter, so people won't feel bad when they're doing it, and then we talked about introducing pancreatic enzymes and continuing to move somebody through the process, until eventually, we're able to use hydrochloric acid if needed, or not, but get to that place of being able to wean people off PPIs, so they can absorb nutrients.

Conclusion

We really enjoyed having the collaborative communication from colleagues who shared their thoughts about the Five R Program and their tricks for getting patients off PPIs, just realizing none of this is easy. There is strength in terms of affirmation, knowing that we're all on this journey together, but also coming towards solutions for that. 

If you have follow up questions or perhaps solutions to contribute to the conversation, reach out any time!