Heartburn Drugs Typically Not Necessary

gerdProton Pump Inhibitors (PPIs) such as Nexium, Prevacid, and Protonix, are some of the most widely prescribed drugs in the U.S.  They are typically given to patients who complain of heartburn or reflux (GERD), who are then kept on the medication indefinitely.  In fact, it’s not uncommon for many of the patients I see to think of being on this medication almost as an afterthought, because it’s so common in our culture.  What they may not realize is that long-term use of these medications can lead to long-term complications, and may be doing more harm than good!

When first approved by the FDA, the suggested use of PPIs was for 4-6 weeks, mainly for treating serious gastrointestinal issues, like ulcers and Barrett’s esophagus.  However, because these drugs are more effective for relieving symptoms of GERD than other medications, they became the treatment of choice for general complaints of “indigestion”.  While some doctors may be closely monitoring these medications, and weaning their patients appropriately, it’s more common for patients to be on PPIs for years without anyone questioning whether they still need them or not.  This is a serious problem, as a number of long-term risks have been associated with PPIs.  In 2012, the FDA issued warnings about Clostridium difficile-related diarrhea, which can be extremely challenging to treat, especially in the elderly population.  In 2011, the FDA warned doctors about the risk of magnesium deficiency with the use of PPIs, which can potentially lead to arrhythmia and seizures.  They even recommended that doctors screen their patients for low magnesium before prescribing PPIs.  In reality, how many doctors are actually following this protocol?  This doesn’t even include other documented risks of long-term PPI use, such as iron-deficiency anemia, vitamin B12 deficiency, increased fracture risk, and increased risk of pneumonia.

The guidelines established by the American Gastroenterological Association suggest that GERD or dsypepsia without any serious complications use PPIs for only 4-6 weeks, followed by the use of less potent acid blockers (ranitidine) as needed.  This greatly reduces the risk of long-term complications associated with these medications.  In my experience, there is typically an underlying cause for symptoms of GERD, whether it’s diet, stress, and/or medication side-effects.  Fortunately, it’s not impossible for you to wean off PPIs, it just takes patience to gradually taper the dosage, while simultaneously addressing underlying causes.  There are a number of natural agents, such as DGL, aloe vera, and D-limonene, that can help to heal irritated gastroesophageal tissue to make the transition of discontinuing the medication more tolerable.  Plus, these agents can be used for ongoing symptom management without having the harmful side-effects of PPIs.

Believe me, I’ve seen a number of patients who never thought in a million years that they would be able to stop their PPI medication, in fear of the reflux symptoms coming back with a vengeance.  But, with the proper guidance and attention to detail, it can be done!

 

IBS? It May Be Something Else . . .

SIBOPeople often come to my office saying they’ve been diagnosed with IBS.  They may complain of intestinal pain, constipation, diarrhea, or all of the above, yet all of their test results come back “normal”, so they are prescribed anti-spasmodic medications to manage their symptoms, and sent on their way.

In my experience, IBS is merely a symptom of other underlying causes, rather than  a definitive diagnosis.  Whether it’s food intolerances, poor eating habits, or restoring optimal production of stomach acid and digestive enzymes, naturopathic medicine has a lot to offer when it comes to identifying and treating the underlying cause of IBS.

One cause in particular that’s often overlooked is small intestine bacterial overgrowth (SIBO).  It’s thought that SIBO is responsible for over 50% of IBS cases, and possibly as much as 84%.  SIBO occurs when bacteria that normally live in the bowels (E. coli, Bacteroides, etc.) are allowed to replicate to excessive levels.  This can occur for a number of reasons, but poor gastric motility (especially due to the use of proton pump inhibitors) is usually the main underlying cause.  The main symptoms of SIBO include: Bloating, gas, abdominal pain, cramping, nausea, heartburn, joint pain, and/or fatigue.

Testing for SIBO can be easily performed using breath tests that detect abnormal levels of hydrogen or methane gas that are produced by excess levels of bacteria.  Once detected, it can be effectively treated with either naturopathic or pharmaceutical interventions.  Eradication of SIBO usually leads to a 75% reduction in IBS symptoms, and is even more effective when combined with dietary interventions (especially low carbohydrates) and motility agents.  Once treated effectively, preventive measures can be taken to reduce the risk of recurrence, which can be high if measures aren’t taken to correct the underlying imbalances that led to SIBO in the first place.

So, if you’ve suffered from IBS for years, see to it that your medical doctor or naturopath test for SIBO, especially since the testing is simple and affordable.  If there’s roughly a 75% chance of your symptoms resolving, your years of waiting for relief are hopefully over!

Does Arthritis Originate in the Gut?

I see quite a few patients with rheumatoid arthritis, and other autoimmune arthropathies, and what is the first thing I do?  Give them anti-inflammatory medications?  Give them immune-modulaters?  No!  Chances are, their rheumatologists have already done this.  The first thing I will always do with patients in this category is address their digestive health.  What does digestion have to do with systemic inflammation?  Everything!

If you think about it, the intestines are really the main barrier that separate us from the outside world.  They have to be extremely selective about what they let in and what they keep out.  Immune cells constantly patrol the intestinal barrier, attempting to keep foreign invaders from entering the circulation.  Enzymes and microbes help to break down foods, assuring that only the nutrients we need are allowed to pass through.  We take this whole process for granted, but the level of intricacy at which everything must stay in check is astounding!

When it comes to rheumatoid arthritis, our biggest concern with respect to intestinal health is an increase in permeability (“intestinal hyperpermeability” or “leaky-gut syndrome”).  The causes of this are numerous, but can include stress, food allergies, intestinal inflammation, medications, genetic influences, and exposure to environmental toxins.  Normally, your intestinal cells are bound by “tight junctions”, which are meant to prevent undigested foods from passing through the intestines into the bloodstream.  So, when your body is exposed to substances that are pro-inflammatory, the intestines can usually limit any negative effects with a localized immune response.  However, when various factors (as mentioned above) affect intestinal permeability, antigens are able to bypass the intestinal immune response, allowing them to mobilize throughout the body, causing a systemic inflammatory response.  The body then begins to attack itself because it’s primary defense (the intestinal barrier) has been compromised, forcing other parts of the immune system to become overactive.  Thus, it’s not surprising that a wide range of gastrointestinal and systemic disorders are associated with abnormal intestinal permeability.  According to a 2003 article in the Journal of Gastroenterology and Hepatology, systemic lupus (SLE), juvenile arthritis, eczema, sarcoidosis, psoriasis, inflammatory bowel disease, and a number of other chronic disorders can be linked to intestinal hyperpermeability.

So, what do most doctors instruct their patients with auto-immune disease to do?  Take NSAID medications.  What do these medications do?  Increase intestinal permeability!  They may temporarily relieve the pain, but the approach of using NSAIDs and immune suppressants is not sustainable, and is most likely worsening the long-term prognosis of auto-immune arthropathies.  While a number of respected journals have discussed the link between intestinal hyperpermeability and systemic inflammation, this concept is largely ignored by conventional rheumatologists.  Repairing the gut needs to be the first line of defense when dealing with auto-immune disease.  Otherwise, as long as antigens continue to be able to “slip past” the intestines, it will be impossible for the immune system to regain control of itself.

What should you do if you have an auto-immune disease, or if leaky gut is a potential concern?  If you want a more definitive assessment, there are tests that can be performed to measure the severity of intestinal permeability.  Comprehensive stool testing can also be performed to evaluate the bacterial environment of the intestines, including the overgrowth of any foreign microorganisms that may need to be dealt with.  A doctor who has experience with treating leaky gut will then need to determine which factors are contributing the most, whether it be food allergies, stress, or medications.  Once these underlying obstacles are removed, nutritional interventions which help to initiate intestinal healing can then be implemented.

The concept of a “leaky gut” is not new to naturopathic medicine.  Even though it has begun to gain traction in conventional medical journals over the last 10 years, it’s certainly far from being the “standard of care” in rheumatology practices.  If you are suffering from any form of auto-immune inflammation, whether it be inflammatory bowel disease, rheumatoid arthritis, or psoriasis, you seriously need to address the underlying causes that may be affecting your digestive health.  While the connection may not seem obvious at first, healing the gut will be the most important step you can take towards stabilizing any systemic form of inflammation.

 

 

What Can I Do About C. diff?

A patient came to me recently after finishing her 2nd course of antibiotic treatment for Clostridium difficile (C. diff) infection.  Despite some temporary relief during while taking the medication, her symptoms were beginning to return to the same level of intensity that she was experiencing before the treatment.  The patient’s gastric distress was so severe that she barely had the ability to function at work, having to take both prescription and OTC pain relievers just to get through the day.  She was reluctant to go through another round of antibiotics, since they weren’t giving her any relief, and were causing other side-effects as well.

In most cases, C. diff infections are acquired in hospitals or long-term care facilities, especially in patients who have been taking antibiotics.  However, due to an increase in antibiotic resistance, more and more patients who are otherwise healthy, and not in a hospital setting, are acquiring C. diff infections.  The patient in question fits into this category-she is young, active, and doesn’t have a history of any serious medical complaints.

Fortunately, Saccharomyces boulardii exists as a viable treatment option for C. diff infections.  Saccharomyces boulardii (SB) is a non-pathogenic strain of yeast that is isolated from lychee and other tropical fruits.  Since it is a yeast, rather than a bacteria, it’s not susceptible to being affected by antibiotics, as are other beneficial microorganisms within the intestine.  SB has been proven to effectively treat C. diff infections, and may prevent the recurrence of C. diff infections by up to 50%.  This is especially important for patients undergoing immunosuppressive therapy for inflammatory bowel disease, along with those in a hospital or long-term care setting.  Given the evidence, it should be standard practice for doctors to be recommending SB for at-risk patients, or those with an active infection.  Unfortunately, I’m not seeing it done nearly enough!

In the instance of the aforementioned patient, a week-long course of treatment with SB completely resolved her gastrointestinal symptoms.  Repeat stool testing showed no sign of C. diff, and other infections were ruled out as a precaution.  Frankly, I was even amazed at how effective the treatment was, given the nature of most C. diff infections!  If you’re someone who is potentially at risk of acquiring C. diff, just know that drugs aren’t the only available treatment option.  Tell your doctor that you’ve read about the effectiveness of SB, and make sure you start taking it ASAP!

 

Acid-Blocking Medications Aren’t Meant For Long-Term Use!

While I may have written about this more than once in the past, I feel like it’s a topic that continues to need revisiting.  A recent New York Times article (http://well.blogs.nytimes.com/2012/06/25/combating-acid-reflux-may-bring-host-of-ills/) highlights the many reasons why proton pump inhibitors (PPI’s), such as Prilosec, Nexium, and Prevacid, can cause more harm than good when used beyond the recommended window of 8 to 12 weeks.  While it seems to come as a surprise to the doctors who are handing out these medications like candy, our stomachs are supposed to make hydrochloric acid!  This is essential for initiating the digestive cascade that leads to the proper assimilation of nutrients.  As the article points out, blocking stomach acid production for an extended period of time can lead to a host of nutritional deficiencies, including iron, vitamin B12, and magnesium.  A decrease in stomach acid also takes away the protective barrier meant to protect us from harmful bacteria, setting up an environment that’s more prone to infection with Clostridium and other pathogenic bacteria.

I personally have seen countless patients in my practice who have been taking one PPI or another for years, and don’t even know why!  In many cases, I’ve seen young women who have persistent iron deficiency anemias, only to find out they have been on acid blocking medication for several years.  However, getting these patients to discontinue the offending medications proves to be extremely challenging, as the body increases the amount of acid-producing cells while on the meds.  Thus, the rebound production of acid is overwhelming, leading to more heartburn than the patient may have ever experienced before even starting the medication!

Fortunately, there are herbs and nutrients that can help to minimize the irritation that can occur when trying to wean off PPI medications.  Once you make the decision with your doctor to discontinue these medications, seek out a qualified naturopathic physician who can help to ease the transition.  Even if you were having legitimate symptoms before these medications were prescribed, it’s likely that diet and lifestyle changes will make a huge difference, without having to depend on a medication that is likely to be more risky than beneficial.

Celiac Disease or Gluten Intolerance?

When people are experiencing nutritional deficiencies, anemia, weight changes, and/or other symptoms that seem to be of an unknown origin, it’s fairly common practice for doctors to rule out the presence of celiac disease with a small intestinal biopsy. While this is certainly considered the “gold standard” for identifying the pathological changes associated with celiac disease, many experienced physicians are finding that patients can still have a sensitivity to gluten containing grains, making celiac disease and gluten intolerance separate entities altogether.  This led experts at the recent International Celiac Disease Symposium to define the term gluten insensitivity for patients who don’t meet the criteria for celiac disease or wheat allergy, yet improve dramatically when following a gluten-free diet.

The incidence of Celiac disease has doubled since 1974, and gluten sensitivity alone is estimated to be 6 times the prevalence of celiac disease. Fortunately, for patients and doctors who have recognized this phenomenon for quite some time, there is finally a more established definition of gluten sensitivity. Some of the criteria being used to separate gluten sensitivity from wheat allergy and celiac disease include: Negative testing for the presence of IgE antibodies to wheat; Negative endomysial and ttg antibodies (typically present with celiac disease); Negative small intestinal biopsy; Resolution of symptoms following as gluten-free diet. Researchers have concluded that the genetic makeup and immune response of gluten sensitivity patients is unique, and may be more enzyme mediated (like lactose intolerance), rather than immune based.

Since objective testing is still lacking, people who are symptomatic should consider implementing a gluten-free diet. Some of the most common symptoms associated with gluten sensitivity include abdominal pain, rashes, headaches, “brain fog”, fatigue, depression, anemia, and joint pain. If your doctor tells you that celiac testing is negative, don’t give up hope!

 

Small Intestinal Bowel Overgrowth and IBS

I’m posting a link here that explains in detail the symptoms of Small Intestinal Bowel Overgrowth (SIBO), and how it is often an underlying cause of IBS. In my clinic, I’ve diagnosed this several times, even after people have already consulted with their gastroenterologist, which indicates that SIBO is not “mainstream” enough for most doctors to pursue the appropriate testing. All that is required is a simple breath test-Once diagnosed, this condition is easily treatable, so talk to your doctor about performing the test if you’re experiencing recurring digestive symptoms, or have been diagnosed with IBS. 

http://www.medicinenet.com/small_intestinal_bacterial_overgrowth/article.htm

IBS and “Mindfulness”

A therapy that combines mindfulness meditation and gentle yoga may help soothe symptoms of irritable bowel syndrome, a small clinical trial suggests.

In a study of 75 women with the digestive disorder, researchers found that those assigned to “mindfulness training” saw a bigger improvement in their symptoms over three months than women who were assigned to a support group.

The findings, they say, suggest that the mindfulness technique should be an option for treating irritable bowel syndrome (IBS).

A doctor not involved in the study agreed.

“I think people with IBS should learn mindfulness skills,” said Dr. Delia Chiaramonte, director of education for the University of Maryland’s Center for Integrative Medicine in Baltimore.

Learning such skills, she said in an interview, is “100 percent safe,” and it could offer people a way to help manage IBS symptoms on their own, long term.

People with IBS have repeated bouts of abdominal cramps, bloating, constipation and diarrhea. The typical treatment includes diet changes, as well as anti-diarrhea medication and, for constipation, laxatives or fiber supplements. There’s also some evidence that regular, moderate exercise helps.

The exact cause of IBS is unknown, but anxiety and less-than-ideal coping strategies — like avoiding going out because of your symptoms — are thought to make IBS worse for many people.

Because of that, psychological counseling is sometimes used. The best-studied form is cognitive behavioral therapy, which tries to change the unhealthy thinking patterns and behaviors that contribute to people’s health problems.

For the new study, Susan A. Gaylord and colleagues at the University of North Carolina, Chapel Hill, looked at a different approach to managing the “brain-gut” connection — known as mindfulness-based stress reduction.

The researchers randomly assigned 75 women with IBS to either undergo the mindfulness training or attend an IBS support group once a week for eight weeks.

The training included lessons on meditation, gentle yoga postures and “body scanning,” in which people focus their attention on one body area at a time to detect muscle tension and other sensations.

Gaylord’s team found that three months after the therapy ended, women who’d undergone mindfulness training were faring better than the support group.

On average, their scores on a standard 500-point IBS symptom questionnaire fell by more than 100 points, with a 50-point drop considered a “clinically significant” improvement.

In contrast, women in the support group averaged a 30-point decline, according to results in the American Journal of Gastroenterology.

Chiaramonte said the trial was “tremendously well-designed,” and set up to address the common criticisms of studies of mind-body therapies. Testing mindfulness training against a support group, for example, helps control for the fact that people involved in any form of therapy may simply expect to get better — and, therefore, do.

In surveys, the researchers found that women in the support group were as likely to expect benefits as those in the mindfulness group.

“And still, the mindfulness group did better,” Chiaramonte said. “So it’s not just the contact with another human being, or not just that they expected to get better.”

It also makes sense that mindfulness training would help people with IBS, according to Chiaramonte. “Part of the problem in IBS,” she explained, “is the attention people give to the physical discomfort, and what the mind then does with that.”

With mindfulness training, the goal is to help people become aware of what they are feeling, but then “let it go” instead of ruminating, and potentially making the physical symptoms worse.

Of course, naturopathic medicine automatically takes “mindfulness” into account, so this is nothing new from my perspective. By always assessing people’s mental/emotional state, along with implementing diet and lifestyle changes, it’s not uncommon for me to see people’s IBS symptoms improve dramatically. It’s unfortunate to see so many patients who come to me after undergoing multiple symptomatic treatments (steroids, anti-spasmodics, etc.), only left to be feeling worse. 

Once again, this study demonstrates what naturopathic med
icine already practices-The impact of the mind on physical health cannot be avoided!

SOURCE: http://bit.ly/lfYimf American Journal of Gastroenterology, online June 21, 2011.

IBS and Exercise

People with irritable bowel syndrome may be able to find some relief by getting regular exercise, a small clinical trial suggests.

The study, of 102 adults with the disorder, found that those who were told to get some more exercise had better odds of seeing improvements in problems like cramps, bloating, constipation and diarrhea.

After three months, 43 percent of the exercisers showed a “clinically significant” improvement in their symptoms — meaning it was making a difference in their daily lives. That compared with a quarter of the participants who maintained their normal lifestyle.

For people who are currently less-than-active, even a moderate increase in exercise may curb irritable bowel symptoms, according to senior researcher Dr. Riadh Sadik, of the University of Gothenburg in Sweden.

In an email, Sadik said the researchers had told those in the exercise group to get 20 to 60 minutes of moderate-to-vigorous exercise — like brisk walking or biking — on three to five days out of the week.

That’s a level that is generally safe and achievable, Sadik said. On top of that, the researcher added, “it will also improve your general health.”

About 15 percent of Americans have irritable bowel syndrome, or IBS, which causes bouts of abdominal cramps, bloating and diarrhea or constipation.

It is different from inflammatory bowel disease, which includes two digestive diseases — ulcerative colitis and Crohn’s disease — that are believed to involve an abnormal immune system reaction in the intestines.

The exact cause of IBS is unknown, but people with the condition often find that they have certain symptom “triggers,” such as particular foods, larger-than-normal meals or emotional stress. From a naturopathic perspective, we also look at food allergies and dysbiosis (imbalances of gut bacteria) as major underlying causes of IBS.

According to Sadik, exercise may be helpful for several reasons. Past studies have shown that it can get things moving along in the gut, relieving gas and constipation. (Vigorous exercise, however, may worsen bouts of diarrhea.)

Regular exercise may also have a positive influence on the nervous and hormonal systems that act on the digestive tract.

None of the participants in the new study, reported in the American Journal of Gastroenterology, were regularly active at the outset. The researchers randomly asked about half to begin exercising over a 12-week period, with advice from a physical therapist. The rest stuck with their normal lifestyle habits.

At the end of the study, the exercise group reported greater improvements on a standard questionnaire onIBS symptoms. They were also less likely to show worsening symptoms.

Of the exercise group, 8 percent had a clinically significant increase in IBS symptoms, versus 23 percent of the comparison group.

That, according to Sadik, suggests that for a considerable number of people remaining sedentary may only worsen IBS.

“If you have IBS, then you can increase your physical activity to improve your symptoms,” Sadik said. “If you stay inactive, you should expect more symptoms.”  

Naturopathic medicine looks at IBS as a multi-factorial condition, involving physical, mental, and emotional issues, so it makes sense that exercise would have a positive impact when it comes to treating this “condition”. If you have symptoms of IBS, but have not yet explored naturopathic treatments, it would definitely be in your best interest. 

Leave That Acid Alone

As most of my patients know, I’m typically against the suppression of stomach acid, aside from a few rare circumstances. The myth that an overproduction of stomach acid is responsible for numerous digestive problems continues to be perpetuated, leading many patients to take some form of acid-blocking medication, often for life. Since Hydrocholoric Acid (HCl) is essential for nutrient absorption, mineral assimilation, and a host of other functions, I always try to discourage people from using acid-blockers. Now, recent evidence is proving that long-term use of these medications is leading to detrimental side-effects. For more information, visit the following link:

 http://www.npr.org/blogs/health/2010/05/26/127132723/fda-warns-about-bone-risks-from-heartburn-drugs?sc=17&f=1001