The use and availability of proton pump inhibitors (PPI) have become very convenient. The common over-the-counter names of these drugs are esomeprazole (Nexium), lansoprazole (Prevacid) and omeprazole (Prilosec). They are used to treat heartburn and recommended to be used for no more than 14 days. But there seems to be an overuse of proton pump inhibitors.  Unfortunately 1/4 of patients end up taking these drugs for over 1 year, and the majority of the time, these drugs are over-used (2/3 of patients) with no indication for treatment.

When you overuse proton pump inhibitors for the long term, you have an overproduction of acid producing parietal cells, and when these drugs are discontinued, you have a hyperacid environment and the symptoms return which is why people stay on them. There are some indications for staying on these acid blockers. They include: High grade erosive gastritis, Barrett’s esophagus, esophageal strictures from gastroesophageal reflux (GERD), gastroprotection of those at high risk for GI bleed, protection from idiopathic pulmonary fibrosis, eosinophilic esophagitis and Zollinger-Ellison syndrome. So it’s between you and your practitioner on whether long-term treatment is necessary and whether the benefits outweigh the risks. And yes…there are risks.

We need to remember that we need stomach acids for absorption of many nutrients, primarily proteins and minerals. Deficiencies include Vitamin B12, iron, calcium, magnesium, zinc, and folic acid. Other dangers associated with long-term use of PPI’s include osteoporosis, kidney disease, pneumonia, stroke and contracting Clostridium difficile (C.diff) bacterium.

The real concern of the progression to adenocarcinoma with Barrett’s esophagus would make the decision of staying on PPI’s quite easy, except for the fact that studies have found no protective effect.

The same goes for eosinophilic esophagitis which is an allergic condition that occurs in the esophagus. The esophagus becomes inflamed and has difficulty contracting properly, getting more narrow and developing rings or abscesses. Although acid suppression helps manage the symptoms of eosinophilic esophagitis, it should only be used after eliminating foods that are triggering an allergic reaction. Eliminating the triggered foods cures the problem in about 50% of patients. There is also some concern that staying on PPI’s may continue to promote the condition. Acid activates proteolytic enzymes to help break down food to make it more digestible. When acid is not available to stimulate digestion, then exposure to undigested foods can trigger eosinophilic inflammation along the gut’s immune system.

So how can we de-prescribe these medications?

1. Identify foods that trigger your symptoms. Tomato based foods, caffeine and alcohol are common triggers I see clinically. I recommend a food list to my patients that can be found on line. Foods that cause GERD.
2. I treat my patients naturally for a condition known as Helicobacter Pylori (H. Pylori), a bacteria that lives in the digestive tract which can cause similar symptoms as acid reflux and can lead to ulcers in the lining of the stomach. I use a combination product that has mastic gum, bismuth and zinc called “Pyloracil”. Mastic gum is a resin, or sap-like substance that comes from the mastic tree grown in the Mediterranean. It helps reduce stomach acid and protects the stomach and intestinal lining. Studies have shown it also fights bacteria including H. Pylori.  I recommend using it for 3 weeks while reducing their PPI from twice daily to once a day or if once a day use, to 1 every other day.
3. If patients develop heartburn when reducing their PPI dose, I recommend “D-Limonene”, which is an orange peel extract on the days they are off of their medication. This can neutralize gastric acid and supports normal peristalsis. It has been used for the relief of heartburn and GERD.
4. Deglycyrrhizinated licorice works well by soothing the stomach lining. You can find this over the counter in chewable tablets.
5. Melatonin can help symptoms if they primarily occur at night. This sleep hormone increases the tone of the lower esophageal sphincter. Start with 1-3 mg before bed.
6. Acupuncture can also be helpful.
7. Stop the use of non steroidal anti-inflammatory medications (NSAID’s), which includes Naproxen, Ibuprofen and Diclofenac to name a few.

If a person has recurring symptoms that last over 3 weeks after stopping their PPI then they should contact their practitioner for possible referral to a GI specialist for an endoscopy. Make sure you discuss all your over-the-counter meds and supplements with your practitioner.

References: Rakel, D. Clinical Practice Update on De-Prescribing PPI’s. Primary Care. March 17, 2022.

Sun, J. D-Limonene: Safety and Clinical Applications. PubMed.ncbi.nlm.nih.gov. Altern Med Rev. 2007 Sept.

Back pain is no stranger to most of us. About 84% of adults have back pain sometime in their lives. For many people back pain is self-limiting. But it can become more of a problem if it continues more than 3 months which is considered chronic. So what about aquatic therapy for low back pain? A study based out of China randomized supervised aquatic exercise versus traditional physical therapy in 113 adults, ages 18-65 with moderate to severe low back pain (LBP). The study went on for 13 months, and participants were randomized to either supervised aquatic therapy or traditional physical therapy in twice weekly sessions for 12 weeks.

After 1 year, mean scores on a 24-point disability scale improved by about 4 points more among participants in the aquatic exercise group then among those in the traditional physical therapy group, which is a meaningful difference. The aquatic exercise group also had improvement on the pain scale vs the traditional exercise group. Significant improvements in other measures of functioning and sleep also favored the aquatic participants.

Aquatic Therapy, or hydrotherapy as it is otherwise known has been used as an alternative therapy for those with chronic pain, or recovering from an injury or surgery. The natural buoyancy of water helps to reduce weight and eases stress on joints, even those in the spine. It does offer some resistance which can increase strength without muscle fatigue. It can reduce muscular and neurological pain and improve flexibility and range of motion. Plus it can be soothing and comfortable when done in a rehab setting by a physical therapist trained in hydrotherapy.

A study in 2019 sited in Physical Therapy stated that “aquatic exercise produced sufficient muscle activation, intensity and exertion.” It also noted reduction of pain vs land exercises. Several other studies have praised its benefits, including its positive effects in those with spinal stenosis, which is a neurological condition affecting the lower back and neck.

Speak to your practitioner and physical therapist about whether this treatment is right for you. This may be an effective option for managing this very common and difficult to treat condition.

References: Thomm, M. Get in the Water: Hydrotherapy for Pain and Movement. Practical Pain Management 11/11/2021.

Peng M-S et al. Efficacy of therapeutic aquatic exercise vs physical therapy modalities for patients with chronic low back pain; A randomized clinical trial. JAMA Netw Open 2022 Jan 7; 5:e2142069.

 

Viruses have a tremendous capacity to drive chronic disease and illness. COVID-19 is no exception. We now have several terms for the condition that causes lingering symptoms after recovering from SARS-CoV-2 or COVID-19 infection. You may know it as “long-term COVID”, “post-COVID syndrome” or “long-haulers”. The NIH (National Institutes of Health) refers to these symptoms as PASC, which stands for “post-acute sequelae of SARS-CoV-2”. This syndrome is getting more and more press, but I still don’t believe it’s getting enough attention. The amount of people that continue to get COVID-19 infections is staggering and is currently driven by the Omicron variant. The CDC’s summary as of January 16, 2022 reports over 800,000 new cases per day, more than doubling the January 2021 peak! The more cases…the more long-haul symptoms. And long-term COVID can occur with mild symptoms and at any age, gender or with no prior illness or health problems. What we know is that long-haul COVID-19 will be with us for the long-haul.

The reason I am harping on this matter is because I believe Long-Haul COVID will be the main health challenge for health care workers, families, our economy and the work force in decades to come. Post-COVID is a multi-system disease that includes physical, mental and emotional symptoms. There are some health care facilities that are addressing these symptoms as real and looking for causes to help treat patients. But others are brushing the symptoms off as being all in their head and “hysterical” reactions to the stress of the pandemic. After going though tens of thousands of dollars of tests, some people are just going home with an inhaler and being told the symptoms will probably “go away” and to give it some time. How frustrating is that?!!!

In a recent meta-analysis, researchers identified nearly 2000 studies that addressed persistent post-COVID symptoms. The 45 studies appropriate for analysis reviewed about 10,000 patients and 84 discrete symptoms. Nearly 3/4 of the patients reported at least 1 symptom that persisted for an average of 2-4 months and some symptoms as long as 6-8 months. The most common symptoms were fatigue (40%), shortness of breath (36%), anosmia or loss of sense of smell (24%), anxiety (22%), persistent cough (17%), ageusia or loss of sense of taste (16%), and depression (15%). So the facts are there, but without much guidance on specific treatments. And yes…you can develop post-COVID symptoms even if you have been fully vaccinated and received a booster!

Integrative medicine is the best solution to recognizing and treating post-COVID syndrome as we are seeing a significant response in improving symptoms and shortening the course of the illness. Integrative medicine prides itself in treating and helping patients when conventional medical therapies have failed. The NIH (National institute of Health) has recognized that integrative medicine can support recovery from post-COVID disease. Restoring homeostasis plays a key role in integrative medicine even when diseases have no clear treatment.

There is clear evidence (and thousands of studies) for selected integrative medicine approaches that can be used to combat inflammation, repair lung injury or dysfunction, replete nutritional deficiencies, reset autoimmune exacerbated conditions, reduce chronic stress and mitigate fatigue. A comprehensive approach combining oriental medicine, functional medicine, homeopathy, intravenous nutrient therapy, nutritional medicine and herbal medicine are introduced in providing healing support and effective treatment in recovering from COVID-19 infection. Individualizing care is essential as each persons symptoms are unique in their own way as well as their course of recovery.

Theories as to how COVID-19 causes long haul symptoms include:

1. Persistent intermittent viremia causing inflammation resulting in lung, heart, pancreas, and liver end organ damage. Symptoms come and go of having recurring fever, chills, myalgia, fatigue and brain fog.
2. Severe inflammation occurring outside the brain (in the lungs and elsewhere) signals through the blood-brain barrier that activates the brains immune system. SARS-CoV-2 can directly modulate human gene expression and the patterns seen in COVID-19 patients are similar to patterns seen in patients with neurodegenerative diseases (dementias and schizophrenia). Synaptic signaling are impaired in the excitatory neurons that are important in cognition. This can generate symptoms such as poor cognition, mood disorders, hallucinations and delusions.
3. Triggers autoimmune reactions to various organs- more likely those who already have autoimmunity or undiagnosed gluten intolerance. It can attack the central nervous system and can re-activate (wake up) latent viruses such as herpes virus or Epstein Bar virus, leading to extreme fatigue.
4. Wide spread microvascular damage causes micro-clots or endothelial dysfunction. This leads to ischemia, oxidative stress, and inflammation in the brain through the olfactory nerve (nose) where the virus can burrow into nerves and hide genetic material. These reservoirs or “anatomical sanctuaries” become the source of neuro-inflammation.
5. The body fails to completely clear the virus which continues to cause an immune reaction where the immune system attacks healthy tissue, increasing allergies, mast cell activation, muscle and joint pain and re-activates other viruses.
6. Neuropathic mechanisms such as autonomic denervation can cause failure of the vasculature of the lower extremities to maintain resistance while in an upright position leading to blood pooling in the lower extremities and causing unstable blood pressure and tachycardia (high heart rate). This is known as POTS (Postural orthostatic tachycardia syndrome).  This condition is thought to have an autoimmune component.
7. Nutrient depletion occurs, especially those nutrients necessary for mitochondrial function such as glutathione, alpha lipoid acid, CoQ10 and L-carnitine.
8. Hormonal disruption can occur due to the stress of illness which leads to increased cortisol (stress hormone), adrenal and hormone imbalance. Symptoms can be lack of sleep, and difficulty coping and adapting to stress. Pre-existing conditions start to surface such as gluten intolerance, sleep apnea, pyroluria and nutritional deficiencies.

What we know is that post-COVID will be with us for some time. The sooner we address its significance and initiate treatment, the sooner we can get people back to feeling healthy, more resilient and back to work. Integrative medicine has given us the assurance that the body’s healing system is capable of restoring wellness. It may take longer for some depending on the severity of the illness but we need to trust in the wisdom of the body and its healing power. Colorado Covid Care has experienced clinicians that focus on outpatient treatment of people recovering from acute and long-Covid infections. 

Helpful resources are: Colorado Covid Care and Survivor Corp

 

Reference: Alschuler, L, Chiasson, M petal. Integrative medicine considerations for convalescence from mild-to-moderate COVID-19 disease. www.ncbi.nlm.nih.gov.

Yang AC et al. Dysregulation of brain and choroid plexus cell types in severe COVID-19. Nature 2021 July; 595:565.

Marshall, M. COVID and the brain: Researchers zero in on how damage occurs. Nature 2021 July; 595:484.

Cline, H, Einhardt, A. Postural orthostatic tachycardia syndrome: A conundrum for patients and healthcare providers. The Nurse Practitioner.  Jan 2022: 13-19

Nasserie T et al. Assessment of the frequency and variety of persistent symptoms among patients with COVID-19: A systematic review. JAMA Netw Open 2021 May 26; 4:e2111417