DEAR DR. ROACH: I am a retired male over 65 and a former occasional cigar smoker (I quit 15 years ago) as well as a former drinker (I quit seven years ago). About 15 years ago, I was diagnosed with Barrett’s esophagus. I regularly did all the biopsies as required and took my proton-pump inhibitor (PPI) daily as instructed.
This year, I read an article about PPIs contributing to dementia and neuropathy (which I have). My primary care physician also suggested that I switch to over-the-counter H2 blockers as a safer approach. I developed an irregular heart rhythm and soaring blood pressure.
I was then diagnosed with atrial fibrillation (AFib). My stress test and echocardiogram are normal for my age. I am now on some heavy-duty beta blockers, blood thinners and a very expensive rhythm-control drug.
A book I recently read written by two top cardiologists stated that long-term use of PPIs is dangerous and can cause AFib, but a recent article published by the National Institute of Health states the opposite. I also read that an irritated esophagus stimulates the esophagus nerve and triggers AFib. I’m confused now.
Because Barrett’s vastly increases my chances for getting a very aggressive cancer, doing nothing is not an option. I have already modified and continue to modify my diet, but that only goes so far. And as you are aware of, an stroke caused by AFib is often very life-threatening.
My complicated question is, which professional approach would you recommend: PPIs or H2 blockers? Is there a third option? — B.B
ANSWER: There is not a definitive answer on whether PPIs, like omeprazole, increase the risk of AFib. Studies are potentially confounded by the fact that people with AFib sometimes think they have a stomach problem and may take a PPI, leading to a false association between the PPI and AFib. As you say, there have also been studies that suggest a decreased risk of AFib in people who use PPIs.
In my mind, the increased risk of adenocarcinoma of the esophagus as a result of untreated stomach acid reflux in a person with Barrett’s esophagus is the key in this situation, as Barrett’s is a condition where abnormal lining of the esophagus occurs due to years of acid exposure.
I do not believe over-the-counter H2 blockers, like famotidine (Pepcid), are adequate enough to reduce the risk of esophageal cancer, and I advise patients in your situation to use PPIs, despite their known risks.
The data suggesting a risk of dementia are weak. While there might be a small risk, I don’t think the risk is high enough to avoid using a PPI in a person with Barrett’s. B12 deficiency is absolutely a risk in people taking long-term PPIs. Low B12 can certainly lead to neuropathy, but both can be prevented and treated by testing for B12 deficiency and by getting supplementation, if needed.
I am very glad to hear you are getting routine endoscopic surveillance and biopsies so that any abnormal growth of the esophagus can be identified and treated promptly.
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