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Clinical Pearl Wednesday #111

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Todays clinical pearl comes from an Elite NP follower who commented on Clinical Pearl Wednesday #107 which was about proton pump inhibitors (PPIs) and hypomagnesaemia. She wanted to share her protocol for weaning your patients off PPIs. This comes from a combination of both functional and integrative medical approaches:

The PPI Weaning Protocol

The rule of thumb is to taper the patient off the PPI slowly. The higher the dose, the longer the taper. Rebound symptoms may occur for a short period of time just FYI. General guidelines are to reduce the PPI dose by 50% every 4 weeks.

Here is an example of someone who has been taking 40mg omeprazole daily.

Weeks 1-4:

Begin alternating between 20mg/day and 40mg/day.

On days at 20mg, take the PPI with your largest meal.

If needed, supplement with over-the-counter H2 blockers or antacid.

Weeks 5-8:

Reduce intake to 20mg/day. Take the PPI with your largest meal.

If needed, supplement with over-the-counter H2 blockers or antacid.

Weeks 8-12:

Reduce intake to 20mg every other day. Take the PPI with your largest meal. Attempt to transition off the PPI completely after 4 weeks.

General rules of thumb with the tapering protocol:

Prior to starting the weaning protocol:

Client must start 5mg of Melatonin at bedtime for 4 weeks before starting the protocol and stay on it throughout the protocol. Melatonin helps strengthen esophageal sphincters!

Weeks 1-4 of the taper:

Sucralfate (Carafate) 1g prior to meals and before bed for 2 weeks can be prescribed, if indicated (rebound dyspepsia, acid reflux, nausea, etc.).

Weeks 9-12:

If recurring symptoms persist beyond 3 weeks or longer after discontinuation, repeat an upper endoscopy to see if there are erosive changes that would indicate the need for life-long acid suppression. In this case, an H2 blocker can be trialed, as these do not completely block acid production and appear to have less associated complications as compared with PPI’s.

It is best not to suddenly stop PPIs cold-turkey. This can actually do more harm than good. A progressive titration downward (typically over 6-12 weeks) allows the body to adjust, and during the weaning, targeted supplements can help to fortify and soothe the protective mucosal lining in the stomach. (*Side note: It takes a minimum of 120 days to achieve significant intestinal tract lining healing if there is damage or permeability. Therefore, it is vital to consider GI tract lining health and integrity as a separate issue from Stomach acid imbalances.)

Throughout the weaning protocol, implement ALL of the following into regular practice:

a. Take Deglycyrrhizinated licorice (DGL) (over the counter) daily, as directed on the bottle.

Licorice coats and soothes the stomach. Glycyrrhizin is the mineralocorticoid in licorice that causes salt retention, hypokalemia, and high blood pressure. The DGL removes this.

b. Continue (over-the-counter) Melatonin 5mg at bedtime. Melatonin increases the tone of the lower esophageal sphincter.

c. Weekly acupuncture if desired by the patient.

A general protocol is one treatment every 3 to 4 days for 2 to 3 weeks (3–4 sessions). (Chiropractic is also great, especially with individuals who have hiatal hernias.)

d. Supplement with vitamins and minerals that may have been depleted due to reduced stomach acid (B12, Calcium, Magnesium, and Iron). Consider breaking up vitamin doses and using liquid versions when possible, during the weaning protocol.

e. Repopulate the gut bacteria by taking daily probiotics-a type that includes at least 10-14 billion strains.

f. Repair GI tract tissue using one or any combination of the following, daily:

Marshmallow Root: Ingested as a tea up to 5-6 grams daily, or as a tincture, 5mL after meals.

Slippery Elm Root Bark powder. 1-2 Tablespoons mixed with water and taken after meals and before bed. Honey can be added.

Chamomile can be ingested as a tea to reduce inflammation and spasmodic effects. 1-3 grams steeped as a tea 3-4 times per day.

g. Support digestive processes by taking digestive enzymes with each meal. This reduces the burden of an unhealthy digestive tract, allowing for continued digestion while the GI system continues healing. If the gallbladder was previously surgically removed, also include bile salts to help digest heavier foods.

h. Eliminate or restrict junk foods and processed foods, dairy, gluten, artificial sweeteners, and sugar. The GI tract requires an environment of rich nutrients and reduced inflammation to repair itself. If in doubt about intestinal wall integrity, my go-to is Cyrex Labs Array 2 Intestinal Permeability Panel (if you want to go this far).

Remember, PPIs were not designed to be taken long term and for the patients that have been on it for a significant period of time and would like to get off them, try the above protocol which should help lead your patient to a healthier and happier life!

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