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People’s Pharmacy: Havoc from bugs in the belly

Physicians have long recognized that popular pain relievers such as aspirin, ibuprofen and naproxen can harm the digestive tract. These nonsteroidal anti-inflammatory drugs (NSAIDs) are a mainstay of arthritis treatment.

To counteract the stomach irritation they cause, many doctors prescribe proton-pump inhibitors (PPIs) along with NSAIDs. Drugs like esomeprazole (Nexium), lansoprazole (Prevacid) and omeprazole (Prilosec) help prevent stomach ulcers.

A recent review suggests, however, that this combination might be causing havoc in the small intestine (Mayo Clinic Proceedings, December 2014). NSAIDs cause damage not only to the stomach. Such drugs also can injure the delicate lining of the small intestine. As little as two weeks of NSAID treatment caused lesions in the small intestine of more than half of study subjects (Clinical Gastroenterology and Hepatology, February 2005).

Surprisingly, when acid-suppressing drugs are added to NSAIDs, the small intestine suffers even more damage. One study showed that more than 80 percent of patients on such combination therapy end up with lesions after only two weeks (BMC Gastroenterology, May 14, 2013).

Why would PPIs make the digestive tract below the stomach more vulnerable to damage? The answer appears to be in the bacteria living in the small intestine. Acid-suppressing drugs change the ecology of the gut.

The bugs in our belly are supposed to live in harmony. PPIs apparently disturb the balance of different types of bacteria, reducing the protection they normally provide to the intestinal lining. This worsens the damage caused by pain relievers.

Scientists believe that stomach acid normally kills off swallowed bacteria. By reducing acid levels in the stomach, the digestive tract is exposed to germs that would not normally survive. Several serious GI infections have been associated with PPI therapy, including the hard-to-treat germ C. diff (Expert Review of Clinical Pharmacology, July 2013).

Another complication of bacterial overgrowth in the intestines is pneumonia. Regular use of PPIs has been linked to lung infections, especially in older people (Drugs and Aging, January).

Despite these complications, the Food and Drug Administration considers proton-pump inhibitors safe enough for over-the-counter use. Most pharmacies now prominently display Nexium 24HR, Prevacid 24HR and Prilosec OTC.

The warning on such products states that they should not be used for more than two weeks and no more often than every four months. The FDA may believe that this will protect consumers from adverse effects such as fractures or infections, but many people disregard such instructions.

People who would like to know how to treat symptoms of heartburn without relying on powerful acid-suppressing drugs will be interested in our Guide to Digestive Disorders.

To obtain a copy, please send $3 in check or money order with a long (No. 10), stamped (70 cents), self-addressed envelope to: Graedons’ People’s Pharmacy, No. G-3, P.O. Box 52027, Durham, NC 27717-2027. It also can be downloaded for $2 from our website:

It may take some time before health professionals recognize the danger of recommending PPIs together with NSAIDs. Until then, patients need to be vigilant.