High Dose Proton Pump Inhibitors, Are They Any Good?

High Dose Proton Pump Inhibitors, Are They Any Good?

Lindsey from Houston sent us this question: “I am on 40 mg of pantoprazole 2 times a day. I am not getting heartburn, but I am getting a lot of fluid in my throat and a cough with it.  I get a tickle on the left side of my throat and start to cough, and then I choke until I cough up the fluid.  I tried to find a diet for acid reflux online, but it is impossible.  Could you please help me with any of this?”

Dear Lindsey,

High dose proton pump inhibitors (PPIs) like 40 mg of Protonix, Nexium, or Dexilant taken twice daily are rarely indicated. Several studies in the literature have demonstrated comparable efficacy of standard and high dose PPI in terms of heartburn control. Furthermore, PPIs neutralize stomach acid but do not stop gastric content reflux into esophagus. Consequently, as you have eloquently described in your question, acid reflux patients on PPIs, continue to experience food regurgitation and throat irritation in the absence of heartburn. Weakly acidic or non-acid fluid escapes the stomach across a weak anti-reflux barrier. At the throat level, it causes cough, globus, throat clearing, hoarseness, and voice fatigue. In some cases, patients report choking at night. In addition, aspiration pneumonia and asthma may develop. Increasing PPI dosage or changing PPI brand name is common among gastroenterologists. However, these measures are not associated with improved acid reflux symptom control.

By the same token, diet does not stop acid reflux, nor does it cause acid reflux. There is no such thing as an anti-reflux diet. There is no available diet that can restore an anti-reflux barrier and stop chocking episodes at night. Of course, we recommend a reflux friendly diet to avoid exacerbating acid reflux episodes. However, you can still have acid reflux on an empty stomach. As long as your anti-reflux barrier weak, reflux will continue unabated.

Laparoscopic Nissen fundoplication restores the anti-reflux barrier with very high reliability. The minimally invasive procedure is safe, effective, and durable. Following Nissen fundoplication, you can eat a regular diet and sleep without choking. Reflux from stomach into esophagus or throat is completely inhibited. Throat related symptoms will greatly improve, and you no longer need to take PPIs.