What we know about SARS-CoV-2, the virus causing COVID, is that it is here to stay. Information is continuing to evolve and research is still on going as new discoveries are being made. What we DO know is that COVID-19  is not over yet. It is still prevalent in many cities, states and countries and the United States remains stuck at an uncomfortable high plateau of pandemic pain and misery while new variants are driving a case surge in Europe.

We used to think that once you were infected and recovered from the virus your odds of dying were very low and both prior infection and immunization showed an even more protective effect against severe disease in certain populations. Age, underlying comorbidities and gender were the main risk factors for illness severity and reinfection. That was based on surveillance information from January 2020 through May 2021. Things have clearly changed.

Last year we thought that reinfections were relatively rare. Now we are seeing people infected 2, 3 or even 4 times after being fully vaccinated and boosted! What gives???

We have to remember that the virus strain that’s circulating now is very different then earlier strains. If we have been infected with COVID-19 or vaccinated, our body creates an immune response and mounts antibodies against future infections. It recognizes the strain that our body was originally in contact with. But as the virus changes as it has with Omicron, it becomes a fuzzier picture for our immune system to recognize the virus and we get re-infected. Omicron by far has been the Hercules of all variants in that it continues to shape-shift into other versions of itself making it more difficult for our antibodies, B cells and T cells to recognize and shut down a growing infection before the next subvariant arrives. What this means is that Omicron infection may have boosted our immunity against earlier variants, but it is less effective against itself and its subvariants (B.1.1.529, BA.4, BA.5, BA.1, BA2, BA.3, BA.2.H78Y). This poor immunogenicity against itself explains the resurgence of reinfections.

The BA.5 and BA.4 subvariants of Omicron account for 70% of all infections in the U.S. “It is the worst version of the virus that we’ve seen” according to Eric Topol, professor of molecular medicine at Scripps Research. He states that it takes “immune escape” to the next level which enhances transmissibility beyond earlier versions of Omicron. Fortunately due to the immunity build up from the winter omicron wave, there has not been a significant increase in hospitalizations or deaths. The BA.5 is different in its biology in that it is able to evade the body’s immune system and go unrecognized by our T-cells.

The answers are more than alittle murky. Stay tuned…as we wait for more studies and more clear guidance.

References:  http://Variants Dampen Immune Protection

http://SARS CoV-2 Reinfection

http://Long Term Mortality Following SARS CoV-2 Infection

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.