As a kid with CF, I was lucky in that I had heartburn rarely enough that regular use of antacids or PPIs (proton pump inhibitors) was not offered to me by my parents or doctors, so I never developed a dependence on them. But it seems such things are often suggested to CF patients as part of a standard CF routine. Due to a number of factors common in the CF lifestyle (poor diet, frequent antibiotic usage, stress, coughing, etc.) acid reflux, heartburn, and gastroesophageal reflux disease (GERD) are commonplace in the CF population. Yet mainstream medicine understands the problem entirely wrong, and so their standard treatment protocol ends up exacerbating the issue and causing more problems than you started with. I want to briefly discuss why antacids and PPIs are inappropriate for CF (and humans in general) and some alternatives to these pharmaceutical treatments for reflux.
Mainstream medicine and the media has an incorrect understanding (largely perpetuated by antacid/PPI company commercials) that heartburn is caused by excess stomach acid. In fact the opposite is true in about 90% of cases. Heartburn/reflux is caused by low stomach acid because when the stomach acid is too low, the lower esophageal sphincter (see above picture), which is the valve between the stomach and esophagus, cannot close in response to the appropriate level of acidity and so the sphincter remains open, allowing stomach acid to move up into the esophagus and cause burning and pain. So then why do antacids/PPIs work?, you may ask. That's because they temporarily neutralize the acidity in the stomach with a basic substance (with an antacid) or inhibit the enzymatic cascade that allows the stomach's parietal cells to secrete hydrochloric acid (with a PPI). They do nothing to address the real problem, which is a sluggish response of the lower esophageal sphincter (LES) to close in response to acid. So even if you take an antacid or PPI, the LES will remain open and your stomach acid will be lower than it was before, so the next time you eat something you've set up the perfect situation for this whole problem to start up all over again. This is why regular use of antacids and PPIs causes dependence - if you become dependent on them you get heartburn anytime you eat without them. And the problem often just gets worse and worse, because by using these drugs you're reducing your stomach acid more and more, digging yourself a deeper and deeper hole.
You'll notice on bottles of antacids and PPIs that the labels say they are for short term and infrequent use only. This means using them once every month or so (or less often). Every week or every day is frequent and long-term use. These drugs were not originally designed for frequent or long-term use, yet doctors (even CF doctors) prescribe or recommend their long-term usage all the time. If you look at what these drugs are approved for by the FDA, it's for short term use only. The FDA has approved the use of PPIs only for three 14-day periods within one year. That's it. Not everyday for the rest of your life! That's medical malpractice. Long term use is associated with many side effects including bone demineralization and fractures, anemia, indigestion (especially of proteins), increased risk of catching food-borne, water-borne, and hospital-acquired gut infections (including Clostridium difficile), and dysbiosis [see this link for the latest FDA warnings on PPIs]. The incomplete digestion of proteins can increase susceptibility to developing autoimmunity and food sensitivities. Furthermore, low stomach acid is associated with delayed gastric emptying, or gastroparesis [1, 2], something many CFers struggle with. Stomach acid is an absolutely critical part of our digestive and immune systems (see my previous article to get a description of this in greater detail).
Alternatives
So now that we know that antacids and PPIs exacerbate (not help) the problem of reflux, what are the alternatives? The long-term solution is to bring the level of stomach acid back to normal by increasing it. There are three ways to do this: 1) take a tincture of bitter herbs before every meal; 2) drink a tablespoon or two of apple cider vinegar (ACV) or lemon juice in water before every meal; 3) take Betaine HCL with every meal. Bitters are the most ideal solution to this issue because they are quick, portable (I carry a little 2-ounce bottle with me everywhere), and increase all digestive secretions, not just stomach acid, including bile, saliva, and pancreatic enzymes (in pancreatic-sufficient individuals). Bitters are a very traditional remedy used for thousands of years in many cultures around the world. I take a dropperful of bitters (often a mixture of dandelion, burdock, yellowdock, gentian, motherwort, etc.) straight on the tongue 5-15 minutes before a meal. Bitters can also be taken after a meal to prevent post-meal reflux. A good company to get them from is Urban Moonshine. Apple cider vinegar is another simple and natural solution, especially when first making the transition from antacids to bitters. Bitters or ACV can be used anytime you feel heartburn coming on, in place of antacids. The first couple of days during the transition period may be a little rough, but as your LES starts to relearn how to respond to acid again, you shouldn't feel burning anymore. Needless to say, none of these three remedies should be taken concurrently with PPIs or antacids, as they will cancel each other out.
Betaine HCL is used in situations where the level of stomach acid has dropped so low that it becomes necessary for someone to take supplemental hydrochloric acid for a period of time until the stomach can begin to create enough on its own. There is a very specific way to take Betaine HCL correctly, so I will refer you to the guide created by the smart people at SCD Lifestyle. Eventually as the stomach acid level begins to come back to normal, use of Betaine HCL can be phased out and replaced with ACV and/or bitters.
The only time bitters, ACV, or Betaine HCL is contraindicated is if there is an active ulcer or something worse, like Barrett's esophagus. If this is the case, then the first step is to start with soothing demulcent herbs like marshmallow root and aloe, and resins like in calendula and rose tea. These herbs will help coat, sooth and heal the tissue in the stomach and esophagus so that later on it will be safer to increase the level of stomach acid back to normal. If there is an ulcer that may be caused by a pathogen (many are), such as H. pylori, a two-week course of goldenseal tincture may be indicated to kill the bacteria and heal the tissue. Calendula is also antimicrobial, and is especially helpful in this situation as well. Ulcers and bleeding of the stomach and lower GI can also be caused by frequent and prolonged use of NSAIDs (ibuprofen, aspirin, etc.), which degrade the mucosal lining of the GI tract. Therefore, it is advised to reduce or stop use of NSAIDs before trying to rebalance the stomach acid with one of these three methods.
Conclusion
Antacids and PPIs are overused and can be dangerous when misused. If you or someone you know is on an antacid or PPI long term or frequently, please consider the unnecessary harm that is being done to the entire body with these drugs. Reflux is not an inherent part of CF, it is simply caused by the co-factors of a CF lifestyle. You can prevent developing reflux by ensuring that your level of stomach acid is always robust and healthy. There are a number of studies out there linking stomach acid-lowering drugs to many different health issues, so I suggest you search pubmed.gov to find out more. If you end up making the transition off of PPIs/antacids, I would love to hear how you did it and how it went for you.
You'll notice on bottles of antacids and PPIs that the labels say they are for short term and infrequent use only. This means using them once every month or so (or less often). Every week or every day is frequent and long-term use. These drugs were not originally designed for frequent or long-term use, yet doctors (even CF doctors) prescribe or recommend their long-term usage all the time. If you look at what these drugs are approved for by the FDA, it's for short term use only. The FDA has approved the use of PPIs only for three 14-day periods within one year. That's it. Not everyday for the rest of your life! That's medical malpractice. Long term use is associated with many side effects including bone demineralization and fractures, anemia, indigestion (especially of proteins), increased risk of catching food-borne, water-borne, and hospital-acquired gut infections (including Clostridium difficile), and dysbiosis [see this link for the latest FDA warnings on PPIs]. The incomplete digestion of proteins can increase susceptibility to developing autoimmunity and food sensitivities. Furthermore, low stomach acid is associated with delayed gastric emptying, or gastroparesis [1, 2], something many CFers struggle with. Stomach acid is an absolutely critical part of our digestive and immune systems (see my previous article to get a description of this in greater detail).
Alternatives
So now that we know that antacids and PPIs exacerbate (not help) the problem of reflux, what are the alternatives? The long-term solution is to bring the level of stomach acid back to normal by increasing it. There are three ways to do this: 1) take a tincture of bitter herbs before every meal; 2) drink a tablespoon or two of apple cider vinegar (ACV) or lemon juice in water before every meal; 3) take Betaine HCL with every meal. Bitters are the most ideal solution to this issue because they are quick, portable (I carry a little 2-ounce bottle with me everywhere), and increase all digestive secretions, not just stomach acid, including bile, saliva, and pancreatic enzymes (in pancreatic-sufficient individuals). Bitters are a very traditional remedy used for thousands of years in many cultures around the world. I take a dropperful of bitters (often a mixture of dandelion, burdock, yellowdock, gentian, motherwort, etc.) straight on the tongue 5-15 minutes before a meal. Bitters can also be taken after a meal to prevent post-meal reflux. A good company to get them from is Urban Moonshine. Apple cider vinegar is another simple and natural solution, especially when first making the transition from antacids to bitters. Bitters or ACV can be used anytime you feel heartburn coming on, in place of antacids. The first couple of days during the transition period may be a little rough, but as your LES starts to relearn how to respond to acid again, you shouldn't feel burning anymore. Needless to say, none of these three remedies should be taken concurrently with PPIs or antacids, as they will cancel each other out.
Betaine HCL is used in situations where the level of stomach acid has dropped so low that it becomes necessary for someone to take supplemental hydrochloric acid for a period of time until the stomach can begin to create enough on its own. There is a very specific way to take Betaine HCL correctly, so I will refer you to the guide created by the smart people at SCD Lifestyle. Eventually as the stomach acid level begins to come back to normal, use of Betaine HCL can be phased out and replaced with ACV and/or bitters.
The only time bitters, ACV, or Betaine HCL is contraindicated is if there is an active ulcer or something worse, like Barrett's esophagus. If this is the case, then the first step is to start with soothing demulcent herbs like marshmallow root and aloe, and resins like in calendula and rose tea. These herbs will help coat, sooth and heal the tissue in the stomach and esophagus so that later on it will be safer to increase the level of stomach acid back to normal. If there is an ulcer that may be caused by a pathogen (many are), such as H. pylori, a two-week course of goldenseal tincture may be indicated to kill the bacteria and heal the tissue. Calendula is also antimicrobial, and is especially helpful in this situation as well. Ulcers and bleeding of the stomach and lower GI can also be caused by frequent and prolonged use of NSAIDs (ibuprofen, aspirin, etc.), which degrade the mucosal lining of the GI tract. Therefore, it is advised to reduce or stop use of NSAIDs before trying to rebalance the stomach acid with one of these three methods.
Conclusion
Antacids and PPIs are overused and can be dangerous when misused. If you or someone you know is on an antacid or PPI long term or frequently, please consider the unnecessary harm that is being done to the entire body with these drugs. Reflux is not an inherent part of CF, it is simply caused by the co-factors of a CF lifestyle. You can prevent developing reflux by ensuring that your level of stomach acid is always robust and healthy. There are a number of studies out there linking stomach acid-lowering drugs to many different health issues, so I suggest you search pubmed.gov to find out more. If you end up making the transition off of PPIs/antacids, I would love to hear how you did it and how it went for you.
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