H2RAs vs PPIs?

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GDen
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   Posted 12/6/2009 7:01 PM (GMT -7)   
Anybody here use H2 receptor antagonists (Tagamet, Zantac, Pepcid, Tazac/Axid, etc.)? I've read they're less effective than proton pump inhibitors (Aciphex, Prilosec, etc.), but they're also a lot less expensive. I've also read that subsequent H2RAs have greatly reduced side effects compared to the original (Tagamet). I get stomach pains occasionally and currently take PPIs.
Cimzia, Asacol

Post Edited (GDen) : 12/6/2009 7:05:28 PM (GMT-7)


FunGuy
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   Posted 12/6/2009 7:04 PM (GMT -7)   
As far as expense. If you have good prescription insurance you can get the prilosec cheaper I think. I get mine through mail refills from kaiser permanente. I get a three month supply for 10 or 20 bucks if I recall.

Post Edited (FunGuy) : 12/7/2009 11:02:34 PM (GMT-7)


Keeper
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   Posted 12/7/2009 2:31 PM (GMT -7)   
PPI's are effective - too effective. They raise the pH of your digestive juices (less acid) to the point where your digestive enzymes don't work properly. This results in undigested food entering your small intestine where it triggers the peristaltic brakes (the SI has sensors that detect undigested food - mainly fats - and slows peristalsis to allow for more complete digestion). Slowing the transit speed allows bacteria to multiply in the SI and this can cause SIBO which is one of the causes of symptoms like gas, bloating, diarrhea or constipation (depending on the species of bacteria predominating) and pain. SIBO can occur in Crohn's without any help from PPI's due to strictures and inflammation, but there is no reason to add fuel to the fire. SIBO may be at the root of many complications like pancreatitis and gall stones.

The H2 blockers may be more appropriate for Crohn's because there is reason to believe that the stomach acid problem is due to intestinal inflammation via increased histamine production in the stomach (several possible causes). One other thing that you might want to try is digestive enzymes. If you have insufficient lipase from your pancreas, that will result in slowing of your transit time and that causes the normal stomach contractions to be unable to empty the stomach normally. Those stomach contractions then result in pushing the stomach contents back up the esophagus. There can be other problems, so this may not apply in your case.

GDen
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   Posted 12/7/2009 10:44 PM (GMT -7)   
Hmm, I hadn't heard about PPIs and SIBO. I think I recently read something though that PPIs could cause calcium deficiency problems.

I checked PPI prices at my Canadian pharmacy and they were pretty much the same as in the US, which is weird. Except for one type of PPI which is generic there.
Cimzia, Asacol


Keeper
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   Posted 12/7/2009 10:58 PM (GMT -7)   
I should qualify the SIBO caution. Researchers say that PPI's cause SIBO, but not at a "clinically significant" level. I think that it is not a good idea to promote low level SIBO in Crohn's, even if the doctors are content to ignore it.

FunGuy
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   Posted 12/7/2009 11:08 PM (GMT -7)   
Keeper that is interesting stuff about the slowing of peristalsis from PPI's. I wonder how that relates to another posting on this forum that said many of us seem to have accelerated peristalsis. I have noticed it in myself that food seems to pass through my system quickly. PPI's could spend more time in the small bowel but move rapidly through the stomach and large bowel?? Curious?

I get a generic omeprazole prilosec of some sort at the pharmacy. I have a co-worker who buys Prilosec at Walmart and I think she pays more.


Keeper
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   Posted 12/7/2009 11:34 PM (GMT -7)   
Well, diarrhea is one of the results of SIBO. It sounds backwards, but bacterial growth there (depending on which bacteria are growing) can cause D. I don't know the full story, but I would guess that it is due to the gut reacting to bacterial immune response or toxins or possibly bacterial infection/invasion in the SI. There are a couple of gut bacteria that are borderline pathogens and the SI is not well equipped to handle large numbers of them. That is one of the most difficult things in sorting out what is happening with this DD. There are cycles of action/reaction that are really complex. And then there are the many stages of progress in associated problems like malabsorption, pancreatitis, electrolyte imbalance, adrenal problems, liver and gall bladder inflammation and on and on.... All of them due to the basic source - Crohn's.

Nanners
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   Posted 12/8/2009 7:38 AM (GMT -7)   
Well I disagree with Keeper. I have been on PPI's for a few years. I do not have diarrhea, do not have any of the other issues they discuss. Many with Crohns suffer with Acid Reflux/GERD due to the Crohns or in my case the surgical changes. If I do not take the PPI's I am MISERABLE with nausea, diarrhea. Pure misery. So I will stick with my PPI. JMHO
Gail*Nanners* Co-Moderator for Crohns Disease & Anxiety/Panic
Crohn's Disease for over 34 years. Currently on Asacol, Prilosec, Estrace, Prinivil, Diltiazem, Percoset prn for pain, Zofran, Phenergan, Probiotics, Calcium, Vit D, and Xanax prn. Resections in 2002 & 2005. Also diagnosed w/ Fibromyalgia, Osteoarthritis, & Anxiety. Currently my Crohns is in remission, but my joints are going crazy!
*Every tomorrow has two handles.  We can take hold of it by the handle of anxiety, or by the handle of faith"*

FunGuy
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   Posted 12/8/2009 9:59 AM (GMT -7)   
I think that there is reason to believe that there could be a number of different things that can cause Crohn's disease AND/OR there are many different possible side effects and associated conditions. I also have used PPI's for years. If I forget to take it in the morning I get a reminder in the afternoon with heartburn. I do get diarrhea regardless of PPI. (Blue dye stops the D for me). There are concerns I have read about bacterial overgrowth with the PPI's due to less acid in the gut. I SUSPECT that in my case that is why I get upper abdominal pain if I take more than one PB8 probiotic capsule. Overall, like Nanners, I am satisfied with and depend on my PPI (Prilosec). Reflux is not something that you can ignore, both for comfort as well as for serious damage to the esophagus it can cause. I guess what I am saying is you are both right in my opinion.


Keeper
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   Posted 12/8/2009 3:24 PM (GMT -7)   
I can't really argue with you - the stuff does its job. I was on a couple of them for over a year - or was it two? Anyway, I was not happy with the fact that I was not able to tell if there was stomach inflammation. Sure, there was no acid reflux, but there was reflux. I found that I was able to control acid reflux by diet control (after a week or two getting past the rebound acidity that happens when you stop PPI's). By watching my diet, I eliminated foods that caused me problems. The resulting diet was an accidental variation on the SCD plan (I did not discover the SCD until a few years later), with a couple of starches (rye and oats and rice) allowed and a mounting belief that sugars and candy were giving me problems (but not wanting to admit that!). I have not had any reflux since then - none. I am sure now that reflux is due to gut inflammation and there are several ways that this can happen, but there is almost no interest in the question in the literature. My useless GI did not seem to have any idea that reflux might be connected with Crohn's and mistook my questions - deliberately? - as asking about Crohn's lesions in the stomach. Anyway, that's my bias - I just don't like having a problem just covered over.

BTW - Nanners, it could be that the low grade SIBO that comes from PPI's did not cause you any problems, but it does cause C as well as D (depending on the bacteria that are overgrowing).

FunGuy
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   Posted 12/8/2009 5:20 PM (GMT -7)   
Keeper what you wrote above is interesting. I want to get off the PPI and don't understand why I can't. Perhaps it is the rebound reflux you mention. Diet control is not my strong point. I have such a limited menu as it is. And I LOVE bread and pretzels. They add to my acid but I don't think I can give them up. HMMM perhaps I should consider this.
I use FD&C Blue dye number 1 and it really seems to help me.  There is SCIENCE behind this.  Just ask me and I will explain it to you.  U/C and Crohn's for 34 years.  Blue dye for one month and I am feeling pretty good!  I am so excited by this but I need others to try it with their doctor's permission.  Simple food coloring!!  BLUE1.  
I can't make money on this, it's already in your kitchen.  I just want to help.
I do 2 drops in 6 ounces of water when I get up, 2 or 3 drops in 16 or 20 ounces of water that I sip all day and then 2 drops in 6 ounces of water at bedtime.   Max of 7 drops a day.  Give it about ten days.  I am NOT a healthcare professional.   Ask your doctor if this is safe for you. 


Wolfie40
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Date Joined Dec 2008
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   Posted 12/8/2009 5:44 PM (GMT -7)   
I was on Protonix and I was having "D" , so my doctor said lets start over and see what is causing this. He took me off the Protonix, reduced my Asacol, add Questran and put me on Pepcid complete.
The "D" is gone so I'm not sure what fixed it. I do know that the Protonix worked way better then the Pepcid as I need to take Pepcid twice a day if not I feel it.
Diagnosed with Crohns in 2001
First and hopefully last Ileocecectomy 2/18/2009

Medications: Asacol, Precription Folic Acid, Multivitamin, 1000mg Calcium, Vitamin D, Probiotics, Pepcid Complete, Questran,  Monthly B-12 injections.

Living a Great life with my Wife and my two Chocolate Labs
Hunter & Hailey.
I love them dearly.


GDen
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Date Joined May 2009
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   Posted 12/8/2009 6:44 PM (GMT -7)   
Since tapering off pred my stomach pains seem to have gone away. PPIs were quite effective when I needed them.

Keeper--that's interesting about the SI. I recently heard that the SI is pretty much a "sterile" environment with very little bacteria. It's the LI that's loaded with bacteria, and a valve between the two keeps them separate. Some IBD patients have to get that part removed, which causes problems due to the two mixing.
Cimzia, Asacol


Keeper
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Date Joined Jun 2008
Total Posts : 1058
   Posted 12/8/2009 11:12 PM (GMT -7)   
Reflux in Crohn's is likely due to intestinal inflammation. There are several likely mechanisms that could be at work and it may be that different ones apply for different people. In my case, since food seems to trigger acid problems, I have to assume that there is some sensitivity to some foods. Food sensitivities are controversial. The problem with them is that they can fade away over a fairly short period of time (weeks to months). They form in the first place because of gut permeability. The gut becomes more permeable from several causes (NSAIDs, alcohol, stress, intestinal infection like Norwalk or food poisoning and any other cause of gut inflammation - like a Crohn's flare). The foods that form sensitivities are usually the ones that you use as a main part of your diet at the time of the permeability increase. That is why wheat gluten (only proteins form antibodies) or even beef have been identified as being a problem. Once a sensitivity has formed, every time thereafter when you eat that food, it will trigger a reaction in the stomach's mast cells (front line immune cells) that causes extra acid to form. It also causes general inflammation which distorts the stomach and the esophageal valve then leaks. This can be fixed by avoiding that food trigger.

Then there is the small intestinal brake effect. Some foods when not properly digested in the stomach are sensed as being undigested and the SI slows peristalsis. The most common food here is fats and oils. With PPI's, some proteins also will slow the SI. This results in SIBO (Small Intestinal Bacteria Overgrowth) and a host of related problems. Here's a link for reference: http://www.practicalgastro.com/pdf/December08/DiBaiseArticle.pdf

The link article mentions low stomach acid (hypo- or achlorhydria) as a cause, but also strictures or low pancreatic enzymes or bile problems can all cause SIBO. All these problems initially slow the passage of food through the SI and result in backing up the digestive process and prevents the stomach from passing its contents into the SI as fast as usual. This results in normal stomach contractions pushing stomach contents back up into the esophagus - acid reflux. Once SIBO is established, diarrhea might result, or constipation could be the result. If it is constipation, the reflux problem would continue.

Once SIBO has happened, the bacteria compete with your gut for the partially digested food. In this situation, starches, sugars and other polysaccherides cause rapid bacterial growth with resulting gas/bloating and pain/sensitivity (and brain fog for me). In my experience, eliminating carbs and sugar while consuming only water - fasting - or predigested foods like clear broth or gelatin will clear the bacterial problem in a day or two. To prevent recurrence, you need to know what caused the problem and adjust your diet or supplements to fix it. The article mentions antibiotics, but there are other problems with using them (the article talks about that a bit). It also mentions probiotics but it is short on any real information about that. This is probably due to the complexity of the problem and individual responses.

Sorry for the long ramble - there's a lot to the subject and I have left out some conjectures.

Nanners
Elite Member


Date Joined Apr 2005
Total Posts : 14995
   Posted 12/9/2009 8:11 AM (GMT -7)   
I was recently treated for SIBO successfully. I believe my constipation is not caused by SIBO, but by the pain meds I use daily. I have pretty bad Osteoarthritis and Fibro and need the pain meds to control it. I will take the c over d anyday. JMHO

Also, as someone else mentioned my reflux is caused by a Hiatel Hernia and the mechanical changes that occurred with my resections. I have been in remission for a few years and all tests show no inflammation. So I dispute your theories, not everything is caused by your SIBO. Again JMHO.
Gail*Nanners* Co-Moderator for Crohns Disease & Anxiety/Panic
Crohn's Disease for over 34 years. Currently on Asacol, Prilosec, Estrace, Prinivil, Diltiazem, Percoset prn for pain, Zofran, Phenergan, Probiotics, Calcium, Vit D, and Xanax prn. Resections in 2002 & 2005. Also diagnosed w/ Fibromyalgia, Osteoarthritis, & Anxiety. Currently my Crohns is in remission, but my joints are going crazy!
*Every tomorrow has two handles.  We can take hold of it by the handle of anxiety, or by the handle of faith"*

Keeper
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Date Joined Jun 2008
Total Posts : 1058
   Posted 12/9/2009 10:57 PM (GMT -7)   
I did not say that SIBO was the only cause - the first bit of my last post was about food intolerances which is caused by a whole different set of foods (proteins) than SIBO. I have a suspicion that hiatal hernia is a result of stomach contractions which are pushing against a resisting SI - whether due to strictures, dietary fat overload, inflammation or SIBO. I too was told that I had a hiatal hernia, I am not sure any more on what evidence.

There is another possibility as well. The fat that wraps around the intestines which is a characteristic of Crohn's could play a role. It is a bit less well understood. They don't know whether it is a result or cause of Crohn's inflammation, for instance. However, they do know that it reacts to intestinal inflammation by producing a flood of extra inflammatory compounds like TNF and IL-1. Since it is on the abdominal cavity side of the intestines, those inflammatory molecules can leak into the space around the internal organs. From there, the inflammation could reach several organs including the stomach. It would have a greater impact if the fat was on a section of the intestines near to or touching the stomach. This is purely a speculation, but it looks possible to me.

GDen
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Date Joined May 2009
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   Posted 12/10/2009 7:13 PM (GMT -7)   
Chronies have increased abdominal fat?
Cimzia, Asacol


Julia Hill
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   Posted 12/10/2009 9:02 PM (GMT -7)   
Zantac worked well for me for many years. After it lost its effect I was put on Losec 20 - also excellent. After this wasn't helping I started Nexium - still on it. I have found that if I take losec 20 in the evening now I will have D. I don't know why, but the the D is a sure thing for me.

Julia

Keeper
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Date Joined Jun 2008
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   Posted 12/10/2009 9:34 PM (GMT -7)   
The fat is internal and wraps around the intestines. It is different from normal fat in that the cells are smaller and consume more energy. Here is a link to an article describing that fat: cells
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