TDDC Response to Patients regarding Proton Pump Inhibitors and Alzheimer’s

Written by Dr. Christopher Vesy, TDDC Gastroenterologist

In February 2016, an article was published in the medical journal JAMA Neurology which suggests an association between a class of commonly used acid reducing medications proton pump inhibitors (PPIs—specifically omeprazole, pantoprazole, lansoprazole, esomeprazole and rabeprazole) and  dementia. 73,679 persons over the age of 75 in Germany were studied.  Of those with dementia, 2.7% were classified as Alzheimer’s type dementia.  We at TDDC take this information very seriously.  We therefore want to share our thoughts with you about this study and any possible association between PPIs and dementia.

In reviewing any study, we must remember that a scientific association is not a cause-and-effect relationship and we must look for other associations which may influence the results.  Most importantly, we cannot jump to cause-and-effect conclusions considering the importance of PPIs which can be lifesaving in patients with ulcer diseases, esophagitis (ulcerative, erosive, Barrett’s or Eosinophilic) or respiratory complications from reflux disease.

Some important points to consider when critically analyzing the JAMA Neurology article are the following:

First, this study is contrary to prior published data suggesting there may be a decrease in the risk of dementia by using a PPI. Furthermore, the New England Journal of Medicine published a study just one week prior to JAMA Neurology showing a decrease in overall dementia from 3.6 per 100 persons in the late 1970s to 2.0 per 100 persons at present. Considering the first proton pump inhibitor (omeprazole) was released in the 1980s, this data is very, very contrary to population use of PPIs actually increasing rates of dementia.

Second, the JAMA Neurology authors did not incorporate or adjust their results for three very important factors which we believe really do have a cause-and-effect relationship with dementia:  alcohol use, family history and high blood pressure.  These factors are considered confounders and, if not removed from the data analysis, will adversely influence the results.  The authors did not make this consideration.

Third, not discussed is data regarding the old class of acid inhibitors—H2 receptor antagonists such as Zantac, Pepcid and Tagamet—and this class of acid inhibitors also has prior studies implicating a possible association with dementia.

On the other hand:

We can never guarantee the long term results of using any medication without proper long term studies.  In regard to PPIs and dementia, we do not have these studies available to us.

We don’t want patients simply using any medication, including a PPI, just for the sake of taking another pill.  Recall that PPIs are now available over-the-counter such as Prilosec OTC (omeprazole), Nexium (esomeprazole) and Prevacid (lansoprazole).  If the medication is being used for occasional heartburn without esophagus, stomach or intestinal diseases as diagnosed by a TDDC physician, then we certainly encourage non-medication interventions such as healthy small and frequent meals, not eating or drinking for a couple hours before lying down, weight loss and avoidance of foods that give symptoms.  Or, if needed, an occasional simple anti-acid such as Tums or Rolaids may suffice.

In short, we find this study to have significant flaws and do not encourage patients to stop their PPI without visiting their TDDC physician.  A frank discussion about the reason for taking a PPI is advised.