Heartburn Medication Tied To Higher Covid-19 Risk

August 18, 2020

Taking a common heartburn medication may modestly increase the risk of contracting COVID-19, according to a new study.

Based on an online survey of more than 86,600 people, more than 3,300 of whom were infected with COVID-19, the results suggest that those taking a proton pump inhibitor (PPI) may be about 2.2 to 3.7 times more likely to be infected with the virus than those not taking that type of heartburn medication. The report was published on July 7 in the American Journal of Gastroenterology.

But before you throw away your prescription, know that the survey can’t establish causation; it only highlights a potential link between PPIs and your chances of contracting COVID-19. Experts told Live Science that in order to show that PPIs actually increase your chances of contracting COVID-19, doctors need to examine the medical records of patients with verified positive COVID-19 test results to see if there are disproportionately high numbers of people using these drugs and to rule out that these patients don’t share other characteristics that might also raise the risk of infection.

“We are by no means saying that people need to stop their PPIs,” said study author Dr. Christopher Almario, a gastroenterologist and assistant professor of medicine at Cedars-Sinai, a nonprofit academic medical organization in Los Angeles.” We have found an association here; again, this needs to be confirmed.” Almario added that many U.S. residents take PPIs to treat severe acid reflux, heartburn or peptic ulcers, and those people shouldn’t have to drop low doses or switch medications without first consulting their healthcare providers.

“The last thing you want to do is create panic for unnecessary causes,” said Dr. Dhyanesh Arvind Patel, a gastroenterologist and assistant professor of medicine at Vanderbilt University in Nashville, Tennessee, who was not involved in the study.

“My sense is that there are a lot of unmeasured confounding factors” in the findings, meaning that some unknown factors shared among PPI users, but not related to their medications, may raise their risk of infection, he said.

Stomach acid as an immune defense system
PPI reduces the amount of acid released into the stomach by permanently blocking the proton pump, a protein that ejects positively charged molecules from stomach cells. The drug disappears as the blocked proton pump is replaced by a new one, as the gastric cells and their surface pumps are continually replaced, Almario said.

According to the textbook Medical Pharmacology and Therapeutics (Elsevier Ltd., 2018), a single dose of PPIs can inhibit acid production by about 90 percent over a 24-hour period.In practice, Almarevio says, this means that PPIs can keep the pH of the stomach at about 6, whereas it usually drops to 3 after we eat.(pH The range is from 0 to 14, with 0 being the most acidic and 14 being the least acidic – or most alkaline.6 has a pH 1000 times lower than 3).

“These drugs have been game changers” for treating patients with gastroesophageal reflux disease (GERD) and peptic ulcers, says Patel. But while reducing stomach acid is beneficial, it may also leave the gut vulnerable to some infections.

For example, according to a 2019 report in the journal Gastroenterology, taking PPIs once a day may increase the risk of contracting Clostridium difficile. acids with a pH of 3 or lower can kill bacteria, thereby protecting the gut from harm. Similarly, acids with a pH of 3 or lower hinder the ability of SARS coronavirus, which causes severe acute respiratory syndrome, to infect cells in a Petri dish, according to a 2004 report published in the Journal of Virology Methods.SARS coronavirus, or SARS-CoV, was the cause of the 2002-2003 outbreak.

“We learned that COVID-19 can infect the digestive system,” Almario said. Given the previous findings on the related coronavirus SARS-CoV, “would reducing stomach acid increase the chances of COVID infection?”

a pinch of salt
This question prompted Almario and his colleagues to conduct a survey in which participants were asked about their history of gastrointestinal problems and whether they were taking PPI or less powerful heartburn medications called histamine 2 (H2) blockers, which block receptors for the compound histamine, one of several substances that trigger the production of stomach acid.

Survey participants were also asked whether they had ever been tested for COVID-19, and if so, whether they tested positive and what symptoms they experienced. People who started taking heartburn medication after being diagnosed with COVID-19 were categorized as “non-users” because the treatment did not affect their chances of contracting the virus.

The authors found that people who took PPIs were more likely to test positive for COVID-19 than those who took H2 blockers and no heartburn medication. In addition, people who took two doses of PPIs a day were more likely to test positive than those who took only one dose.

“The revelation is that PPI use, especially the common but unapproved twice-daily dose, may increase the risk of #COVID19,” tweeted author Dr. Brennan Spiegel, director of research at Cedars-Sinai Health Services and professor of medicine and public health at UCLA, on July 7.” It’s always worth considering whether twice-daily visits are needed, especially for those who are particularly vulnerable to serious illness, “such as the elderly or those with existing medical conditions.

Still, the findings may not be representative of all patients taking PPIs, Patel said.” If you look at the demographics of the patient population…. . it’s a highly unbalanced cohort,” he noted.

In the study, about 86% of people who tested positive for COVID-19 were 39 years old or younger, which does not reflect the distribution of COVID-19 infection across the population. There is no clear explanation for why PPI use puts younger people at higher risk of infection than older people, he said, suggesting that some confounding factor distorts the results. Equally curious is that these younger patients rarely report being diagnosed with gastroesophageal reflux disease, which is the main reason young adults take PPIs, he said. This may reflect people not filling out the survey accurately, but “you can’t verify any of that information,” he noted.

In addition, the survey did not suggest that PPI use was associated with an increased risk of severe gastrointestinal symptoms in people who caught COVID-19, which might also be expected if PPIs allowed the virus to infect the gut more easily, Patel noted. PPIs would not be expected to alleviate the gastrointestinal symptoms associated with COVID-19, which include vomiting, nausea, and diarrhea.

To confirm the potential link between PPIs and COVID-19 risk, Patel said researchers need to collect data at hospitals or doctors’ offices where confounding factors can be better controlled. For example, doctors could track whether COVID-19 patients taking PPIs experience severe gastrointestinal symptoms, are hospitalized, require supplemental oxygen, or die from the virus more often than those who don’t take the drugs. If these trends prove true, the follow-up question will be whether PPIs can be linked to more severe respiratory symptoms, as well, as the virus primarily attacks the respiratory system, he added.

In the U.S., about 1 in 10 people use PPIs, Patel said.Both he and Almario noted that regardless of their link to COVID-19, PPIs should be taken at the lowest possible dose to achieve therapeutic effect, with minimal side effects. For people taking two PPIs a day, they both recommend checking with their healthcare providers to see if it’s possible to switch to a daily dose, or a weaker H2 blocker, especially if their symptoms are under control.

“It’s just good practice, not because of research,” Patel said.