Medical Throwback Thursday Series: Living in a Post-PPI World

February 25, 2016 | By Matthew Watto, MD

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With the recent trashing of PPIs for the last several weeks, including an article (referenced below) in JAMA that suggested an associated higher risk of chronic kidney disease in patients taking PPIs as well as another article (referenced below) suggesting the possible correlation of PPI usage with increased dementia risk, it leaves us practitioners with one question: What to turn to for GERD and dyspepsia?! Like all good Throwback Thursdays, the answer can apparently only be found in the past. So instead of curbsiding a Gastroenterologist, this humble Curbsider hit the books and found the standard of care in all things dyspepsia straight from 1927 for your perusal. Then you and only you can decide if you’ll ever turn back to using PPIs ever again.

Let us first examine the definition of dyspepsia from that time period. Dyspepsia literally meant, “pain, or any uncomfortable symptom associated with the function of digestion.” In fact, the term was not limited to the occurrence of pain while food remains in the stomach (not much different from today).

Getting into the deep part of the 1927 lesson, acid dyspepsia was considered the commonest of the forms. It was thought to be due to an excessive amount of hydrochloric acid, or of acid salts, in the “gastric juice”. There were multiple typical case scenarios, including “young persons of sedentary occupation, who eat irregularly as to time and amount of food, and in the habit of ‘bolting’ their meals.” Another was the “nervous, highly strung individual”.

As all things in the era prior to imaging as we have today, the knowledge of the clinical aspects of symptomology were very expert at the time. These patients are described as having a good appetite and eating more food at a time, with the development of heaviness and heat in the “pit of the stomach”. Furthermore, there is described the feeling of “strangling” in the throat, with a vague sense of constriction. It was noted that relief is temporarily achieved temporarily by the swallowing of saliva, but is short-lived and may lead to further distension.

So what treatments were available? Unlike our modern day smorgasbord of H2 blockers and PPIs among others, things were limited. It was certainly noted that regularity of meal times, limiting the amount of food taken-in during meals, regular exercise (and apparently “open air and cold baths” too…I don’t know about those) provided benefit. The top remedies of the time included fluid sweet cascara mixed with rhubarb and soda or cream of tartar mixed in water. More relevant to today, it was understood at the time that certain condiments, such as vinegar, mustard, pickles and certain foods like red meats and strong stock soups should be avoided.

So there you have it–whether you consider the most recent article-bashing of PPIs to be strong enough to influence your use of them, it always benefits us to look back and see how practice has changed in the past (nearly) century, and to keep in mind that as we go forward our current medical “truths” will become the “throwbacks” of the future.

References:
Lazarus B, Chen Y, Wilson FP, et al. Proton Pump Inhibitor Use and the Risk of Chronic Kidney Disease. JAMA Intern Med. 2016;176(2):238-246. doi:10.1001/jamainternmed.2015.7193.

Gomm W, von Holt K, Thomé F, et al. Association of Proton Pump Inhibitors With Risk of Dementia: A Pharmacoepidemiological Claims Data Analysis. JAMA Neurol. Published online February 15, 2016. doi:10.1001/jamaneurol.2015.4791.  

Health Knowledge: A thorough and concise knowledge of the prevention, causes, and treatments of disease, simplified for home use. Corish, J L. Medical Book Distributors, Inc. New York. 1927.