Mitigating nutritional impacts of long term PPI use
November 5, 2011 2:36 PM Subscribe
Hey, nutrition experts: I need some advice about taking vitamins and supplements with proton pump inhibitors.
Because of an autoimmune condition (scleroderma + Sjogren's) that includes esophageal dysmotility and reflux, I need to be taking a proton pump inhibitor (omeprazole) every day, indefinitely. I've been on it so far for >10 years, and it seems to be doing its job just fine. Unfortunately, it seems pretty well established that PPIs impair absorption of certain nutrients, and long term use can cause deficiencies. I want to mitigate this problem, but I'm having a hard time finding reliable information to work with.
It seems that doctors don't know beans about nutrition. My doctors' approach seems to be to wait until a deficiency causes symptoms, then do every expensive test that Medicare will pay for to rule out every possible non-nutritional cause, then finally say, well, maybe I should take a multivitamin (I do). I'd prefer to avoid the deficiencies in the first place, rather than waiting for them to develop to the point of causing trouble.
Some relevant details: I'm female, 59. My diet is good (vegetarian, not vegan), and I'm not looking to make any major changes there. My weight is fine. My appetite is good, and, except for the reflux, I have no significant digestive discomforts. My iron and vitamin D levels have been low, but have come back up to normal with supplements. I suspect I may also have been low on magnesium; I started taking it on my doctor's recommendation recently for sleep problems, and it has, happily, had a clear positive effect. I have autoimmune hepatitis, some kidney impairment, and gallstones; all these conditions are stable and mild, but I need to avoid taking anything that is apt to aggravate them. I have a lot of symptoms that have gotten slowly worse over the past few years. This could be due to the underlying disease, but I strongly suspect that nutritional deficiencies from long-term PPI use may also be playing a role. I want to prevent that.
I'm also concerned about timing. The PPI works best when I take it before my evening meal. I take the magnesium a couple of hours before that, in the hope that it will be absorbed before the PPI shuts down acid production. I take the iron with breakfast and lunch, along with milk thistle (recommended by GI doc for liver). An hour after breakfast and lunch, I take calcium.
Does anyone know of a website or other source where I can find the answers (preferably, clear, evidence-based answers) to these questions:
Knowing that I'm stuck taking the PPI indefinitely, and that PPIs interfere with nutrient absorption, what supplements should I take to keep my nutritional status as sound as possible? Knowing that I probably absorb nutrients less than optimally, how do I decide how much to take? And since some things interfere with each other, or work synergistically with other things, what's the best schedule for taking them? What lab tests can my doctor do to check for any developing deficiencies?
I've tried researching this on the web, but any useful answers, if they're out there, are buried in a swamp of woo and Snake Oil. I don't even want to expose myself to too much of that, because it causes me confusion, exhaustion and despair. I've found plenty of solid information confirming that using PPIs long term can cause real deficiencies, but no specific guidelines about how to prevent it.
Seeing a nutritionist or dietician wouldn't be a good solution for me right now, though I'd like to do that eventually. I'm mostly housebound, and it's hard to get out and get to all my routine medical visits. I don't want to add more, and I should be able to sort these issues out on my own (with my doctors) if I can find some reliable information to work with. Any suggestions? Thanks!
Because of an autoimmune condition (scleroderma + Sjogren's) that includes esophageal dysmotility and reflux, I need to be taking a proton pump inhibitor (omeprazole) every day, indefinitely. I've been on it so far for >10 years, and it seems to be doing its job just fine. Unfortunately, it seems pretty well established that PPIs impair absorption of certain nutrients, and long term use can cause deficiencies. I want to mitigate this problem, but I'm having a hard time finding reliable information to work with.
It seems that doctors don't know beans about nutrition. My doctors' approach seems to be to wait until a deficiency causes symptoms, then do every expensive test that Medicare will pay for to rule out every possible non-nutritional cause, then finally say, well, maybe I should take a multivitamin (I do). I'd prefer to avoid the deficiencies in the first place, rather than waiting for them to develop to the point of causing trouble.
Some relevant details: I'm female, 59. My diet is good (vegetarian, not vegan), and I'm not looking to make any major changes there. My weight is fine. My appetite is good, and, except for the reflux, I have no significant digestive discomforts. My iron and vitamin D levels have been low, but have come back up to normal with supplements. I suspect I may also have been low on magnesium; I started taking it on my doctor's recommendation recently for sleep problems, and it has, happily, had a clear positive effect. I have autoimmune hepatitis, some kidney impairment, and gallstones; all these conditions are stable and mild, but I need to avoid taking anything that is apt to aggravate them. I have a lot of symptoms that have gotten slowly worse over the past few years. This could be due to the underlying disease, but I strongly suspect that nutritional deficiencies from long-term PPI use may also be playing a role. I want to prevent that.
I'm also concerned about timing. The PPI works best when I take it before my evening meal. I take the magnesium a couple of hours before that, in the hope that it will be absorbed before the PPI shuts down acid production. I take the iron with breakfast and lunch, along with milk thistle (recommended by GI doc for liver). An hour after breakfast and lunch, I take calcium.
Does anyone know of a website or other source where I can find the answers (preferably, clear, evidence-based answers) to these questions:
Knowing that I'm stuck taking the PPI indefinitely, and that PPIs interfere with nutrient absorption, what supplements should I take to keep my nutritional status as sound as possible? Knowing that I probably absorb nutrients less than optimally, how do I decide how much to take? And since some things interfere with each other, or work synergistically with other things, what's the best schedule for taking them? What lab tests can my doctor do to check for any developing deficiencies?
I've tried researching this on the web, but any useful answers, if they're out there, are buried in a swamp of woo and Snake Oil. I don't even want to expose myself to too much of that, because it causes me confusion, exhaustion and despair. I've found plenty of solid information confirming that using PPIs long term can cause real deficiencies, but no specific guidelines about how to prevent it.
Seeing a nutritionist or dietician wouldn't be a good solution for me right now, though I'd like to do that eventually. I'm mostly housebound, and it's hard to get out and get to all my routine medical visits. I don't want to add more, and I should be able to sort these issues out on my own (with my doctors) if I can find some reliable information to work with. Any suggestions? Thanks!
Best answer: This website appears to be based on some evidence, and is from a health system. I found it by googling 'proton pump inhibitors vitamin deficiency'.
The only thing it seems to suggest aside from taking a multivitamin with the mentioned vitamins and minerals is that you could also try cranberry juice.
Have you asked if your primary care physician has a connection with a dietician/nutritionist? They might be able to arrange for you to get a consultation in conjunction with one of your regular appointments. They often have close connections because they refer a lot of diabetic patients.
In addition to the above mentioned levels, your blood counts would show anemia (to go along with iron deficiency or folate/B12 deficiency) and other blood count values can help show what type of anemia it is and thus what might be causing it. You can also get blood levels called ferritin, transferrin, and total iron binding capacity (TIBC) for iron deficiency, if needed.
posted by treehorn+bunny at 10:05 PM on November 5, 2011
The only thing it seems to suggest aside from taking a multivitamin with the mentioned vitamins and minerals is that you could also try cranberry juice.
Have you asked if your primary care physician has a connection with a dietician/nutritionist? They might be able to arrange for you to get a consultation in conjunction with one of your regular appointments. They often have close connections because they refer a lot of diabetic patients.
In addition to the above mentioned levels, your blood counts would show anemia (to go along with iron deficiency or folate/B12 deficiency) and other blood count values can help show what type of anemia it is and thus what might be causing it. You can also get blood levels called ferritin, transferrin, and total iron binding capacity (TIBC) for iron deficiency, if needed.
posted by treehorn+bunny at 10:05 PM on November 5, 2011
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[W]hat supplements should I take to keep my nutritional status as sound as possible?
Magnesium, definitely (PPIs are thought to prevent absorption of magnesium in the intestine), and I'm glad to see you're already taking it.
Possibly Vitamin B12 (reduced stomach acid can interfere with the absorption of protein-bound B12). Additionally, 10 to 30% of those over 60 cannot absorb vitamin B12 (so, while you're not 60 yet, this could be a concern in the future).
Knowing that I probably absorb nutrients less than optimally, how do I decide how much to take?
Recommended adult magnesium intake is 320mg/day for women 31 and older. However, given your kidney concerns and absorption issues, I don't know how much this needs to be altered (it would probably depend on your magmesium levels).
Vitamin B12 has no established toxic level, so it shouldn't matter how much you take, in terms of worrying about going too high (if you take too much, your body will pee out the rest, without harming your kidneys). Normal intake levels for adults should be about 2.4mcg/day, but this will probably need to be higher, or given another way (injection), if you are unable to absorb B12.
And since some things interfere with each other, or work synergistically with other things, what's the best schedule for taking them?
Take the magnesium with meals (so, breakfast or lunch) and with a full glass of water, since that helps absorption (magnesium citrate is absorbed best). Vitamin B12 should also be taken with food (again, breakfast or lunch) for best absorption. In terms of interference or synergy, I wouldn't be worried about it based on what you've said.
What lab tests can my doctor do to check for any developing deficiencies?
Ideally, your doctor would already be doing blood tests for magnesium levels. If not, you should have that done (because low magnesium is bad, and high magnesium can be bad for the kidneys). Also, vitamin B12 levels.
I feel like what I've typed might not be helpful, but hopefully it is (unfortunately, I don't have an actual website to link you to).
posted by smangosbubbles at 9:55 PM on November 5, 2011