Effect Of Ppis On Pots

[davecom]

Proton Pump Inhibitors (PPIs) are an immensely popular drug class and undoubtedly a ton of POTS patients are on them. A recent study shows that they seem to have a cardiological effect and it is related to Nitrous Oxide. This is especially relevant for POTS patients. Here is the study:

http://circ.ahajournals.org/content/early/2013/07/03/CIRCULATIONAHA.113.003602.abstract

Thoughts?

It appears to me that the researchers are indicating that PPIs may actual inhibit blood vessel dilation. Is this a correct interpretation? Could they therefore actually be helpful for POTS?

[Guest Alex]

http://healthimpactnews.com/2013/antacid-medications-linked-to-heart-attacks/

"Any substance that blocks NO production may result in constriction of blood vessels which would increase the risk for heart disease"

http://www.forbes.com/sites/melaniehaiken/2013/07/12/common-acid-reflux-drugs-could-raise-risk-of-heart-disease-new-research-suggests/

"proton pump inhibitors (brand names Prilosec, Nexium, Prevacid) may cause blood vessels to constrict, reducing blood flow.

Studying both mouse and human tissue cultures, the researchers found that PPIs led to an approximately 25 percent increase in a chemical messenger called ADMA (asymmetric dimethylarginine), considered a cardiovascular risk factor.

ADMA suppresses blood vessels’ ability to produce nitric oxide, a relaxant that protects artery walls. Nitric oxide is so important to cardiovascular health that its discovery was honored with a Nobel Prize in 1998."

Not sure if PPI's reduction of NO is necessarily a good thing. I guess I'm going to have to read a bit more about this and the implications for POTS. What I do know is that PPI's have a pretty bad reputation and they can come with serious implications of the health of those taking them long term - see here

http://www.lawyersandsettlements.com/articles/nexium-fracture-risk-side-effects-ppisi/nexium-fracture-risk-side-effects-ppisi-4-19006.html#.UhjxSJK1GAU

Alex

[davecom]

I don't really find most of the previous alarms about PPIs that surprising - by suppressing acid production they inhibit the breakdown of nutrients in the stomach which leads to vitamin deficiencies. Specifically, calcium and B12 need stomach acid for breakdown prior to absorption in the intestines; hence the higher rates of bone fractures with people on long term PPI treatment.

I tried about 5 different PPIs over the last year but each seemed to make my headaches worse. In retrospect, this was all prior to the POTS diagnosis, so it's not clear if the headaches were just from that. My throat is in such constant excruciating pain now that I feel I need to give them another shot. For some reason H2 blockers stopped working, even though I've tried doubling the dose. Some extreme tolerance perhaps, but I don't know. I've tried every home remedy there is. I'm already on the plainest low acid, low fat, gluten free, dairy free, diet you can imagine so I feel I have no alternative at this point.

[RichGotsPots]

NOS inhibitors may have very different effects on biological systems depending on whether they inhibit the syn- thesis of both NO and other species [e.g. NG-nitro--arginine (-NNA) on nNOS] or not (e.g. -NMMA on nNOS)

[RichGotsPots]

NOS INHIBITORS

There are a bewildering array of NOS inhibitors described in the literature and in use as pharmacological tools. Of these the most widely used have been -NMMA, -NNA and its methyl ester prodrug (N G-nitro--arginine methyl ester, ‘ -NAME ’) and aminoguanidine. Table 4 shows the efficacy of some of these in inhibiting the three human NOS isoforms

[RichGotsPots]

Those are from this http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1221991/pdf/11463332.pdf

[davecom]

At this point regardless of its effects on me, I really have no alternative short of surgery - so I'm trying the PPIs again. I've tried every other option... I'll need to roll the dice. I'm starting Nexium, the only one I didn't try before (although yes I know it's an isomer of omeprazole) today.

What's weird is one of my first symptoms a year ago was this unrelenting acid reflux (unrelated to what I eat, when I eat, etc). It seemed to finally be controlled on famotidine and carafate a couple months ago. But it came back with a vengeance a bit over a month ago. It's the real reflux - the acid is not so strong, it's the literal food or other contents moving back up the esophagus - even 8 hours after eating and sitting up/walking the whole time.

The only thing I can figure is its continued small fiber nerve damage causing the LES to not function/other gastrointestinal regulation misery.

[docradmd]

PPI's and the H2 blockers have also been shown to have cholinergic effects. A component of parasympathetic and increased vagal tone may also be at play here as well as decreased NO production.

Dave, Do you think your symptoms may also be related to gastroparesis and slow motility?

The GI symptoms didnt hit me until 3-4 months after the POTs diagnosis/tilt test etc. Perhaps a motility agent may help and/or gastroparesis diet. Just a thought. It was researching motility agents that led me to the cholinergic effects of the PPI's and H2 blockers.

[cgnursegirl]

I find this interesting. I have acid reflux as well, and I have wondered if it was related to POTS. One thing I would add to the discussion is that PPI's can deplete magnesium, so you need to either take a Mg supplement or try other meds for acid reflux. I was taking prevacid until about 2 months ago, I was hospitalized and found out through my lab work that I was low in potassium and magnesium.

[Guest Alex]

cgnursegirl,

I had a similar experience with potassium and magnesium when I was on nexium a while back...I think I mentioned that, but perhaps on another thread. In my case, I don't think I ever needed the nexium, but my PCP insisted I take it just in case my chest pain was due to GERD. It caused more harm than good in my case

Alex

[davecom]

Good ideas about the parasympathetic effects of these drugs. You're saying they actually increase parasympathetic activity? That should actually be helpful right... Any links to articles?

I started Nexium yesterday at 5 AM. Hasn't helped at all so far. However, the severe headaches I had on all the other PPIs did return. I will probably give it another day since I am in so much pain in my esophagus/throat.

I agree gastroparesis may play a role, although I think the primary cause is the LES not functioning. I should try a gastroparesis friendly diet - although my diet is so limited right now that it's not that unfriendly as it is (I was just reading Mayo's gastroparesis diet recommendation).

Yeah I take a magnesium supplement. I have some Potassium salt that I also very occasionally add to food.

[issie]

Have you looked into MCAS? We have to take H2's and H1 daily. Some people take them more than once a day. My doc told me to not take an H2 without an H1. There is another thread on this. The H2's can cause more inflammation and the H1 modify this. He also said that the H2 would convert to H1 if taken by itself if mast cell activation is a problem.

Also, have you ever tried food combining diets. There is a lot of info on this and how the acid needed for certain foods are different. If you combine the foods wrongly - then the reflux gets worse. I have a friend that tried every kind of meds there were for his reflux and his wife - started him on the food combining diet and he no longer has an intestional issues nor reflux. Would maybe be worth looking at.

Issie

[Reintjes]

You might want to investigate SIBO. I also have Pots and developed SIBO. After 5 rounds of intense antibiotics and a Lowfodmap and low acid diet things improved considerably. I can even drink a cup of tea in the morning without symptoms now--something that would have been unthinkable a year ago. There is a connection between PPI and H2 antagonists-- or basically low stomach acid and SIBO and between POTS and slow motility and SIBO. When I was given a PPI things got SO much worse. I had terrible heartburn in my throat and I could not sit up. I had to be completely flat. Getting off of it and taking the antibiotics improved both conditions-- although it did not resolve either of them.