Long term Omeprazole use and B12 deficiency symptoms

[Blondie511]

My mother has been taking Omeprazole for years and suffers from many classic B12 deficiency symptoms...mouth ulcers, pins and needles, dizziness, weakness, vision problems and difficulty walking. I have spoken to countless doctors and none will even consider the likelihood she is B12 deficient. When I ask about blood test results they always say "everything is fine". One doctor didn't even seem aware there could be a problem with long term Omeprazole use.

[Hypopotamus]

Omeprazole puts a protective coating in the stomach and bowel, and is known to decrease the absorption of nutrients. As B12 is one of the hardest nutrients to absorb, this sort of medication will likely cause a deficiency.

I believe that it says on the bottle that this type of medication shouldn't be used on a permanent basis. If it was me, I would stop taking it. Apple Cider Vinegar and Water Kefir are much kinder, and more helpful for stomach issues. including acid reflux.

[Technoid in reply to Hypopotamus]

Omeprazole tablets have a protective coating that ensures that they are protected from being degraded by stomach acid and can reach the small intestine where they can be absorbed.

wearephlo.com/post/omeprazo...

Omepraprazole's mechanism of action is to react with an enzyme called hydrogen potassium ATPase, also known as H+/K+ ATPase, whose main function is to to acidify the stomach, functioning as a "Proton Pump".

en.m.wikipedia.org/wiki/Hyd...

This is why Omeprazole is described as a Proton Pump Inhibitor (PPI). Some studies also suggest a second mode of action, the inhibition of gastric mucosa CA, mentioned here : jpet.aspetjournals.org/cont... .

The overall mode of action and risks/side effects is described well here:

m.youtube.com/watch?v=HOvtE...(Not working as expected?)

Long term use carries a risk of deficiencies of B12, Magnesium, Iron and Calcium. From a personal perspective, considering the risks, I regard these drugs are extremely dangerous to use in the long term. Regular, severe heartburn is usually pointing to an underlying problem (diet, nutrition, illness) which PPI's only treat the symptoms of rather than uncovering and resolving the root cause.

Stomach Acid is required for proper digestion, nutrient absorption and protection from stomach infection. If the only source of B12 in the diet is animal foods, stomach acid is required to break off the B12 molecule from the protein it is attached to.

Supplemental B12 is not attached to a protein and thus does not have this requirement. In the case of PA, the essential Intrinsic Factor protein is missing so, even if stomach acid is adequate, B12 cannot attach to intrinsic factor (which it needs for protection against stomach acid) and therefore will not survive the journey through the intestinal tract to where it can be absorbed. In theory passive absorption would still work (1% of any dose) but is not effective for many PA patients for unknown reasons.

There are very few studies on the benefits of Apple Cider Vinegar for heartburn. That doesn't mean it will or won't work, just that it's an unknown at this point. If you take Apple Cider Vinegar be sure to dilute it or just use sparingly on a salad or mixed into a meal to avoid damaging your tooth enamel.

I am not medically trained.

[FlipperTD]

Scientist, not medic.

She's got the symptoms because she's likely B12 deficient or borderline. If she needs PPIs, then she needs them and should carry on. It would be good to get a baseline serum B12 level, but then look at the possibility of oral megadosing with B12 because these symptoms are unlikely to go away if she carries on with the PPI tablets. A 3 month course would be OK for PPIs, but anything over 12 months is likely to reduce B12 stores.

See a dietitian [a registered one!] and take it from there. A pharmacist should be able to help too.

Good luck.

[doityourself in reply to FlipperTD]

Hi Flipper.All sound advice in my view.

However, I spoke to my pharmacist re PPIs and b12 depletion and she said she's never heard of that link. I do wonder where some of these people do their training. I thought there was a recognised link that 3 months + of PPI had detrimental effect on b12.

We really are swimming against a tide of ignorance.

[helvella in reply to doityourself]

That is a startling admission of ignorance.

The product documentation tells us there is an issue.

From Summary of Product Characteristics (for one random UK Omeprazole product):

Omeprazole, as all acid-blocking medicines, may reduce the absorption of vitamin B12 (cyanocobalamin) due to hypo- or achlorhydria. This should be considered in patients with reduced body stores or risk factors for reduced vitamin B12 absorption on long-term therapy.

medicines.org.uk/emc/produc...

From the same product's Patient Information Leaflet (edited for relevance):

Warnings and precautions

Talk to your doctor or pharmacist before taking Omeprazole capsules

Omeprazole may hide the symptoms of other diseases. Therefore, if any of the following happen to you before you start taking

Omeprazole or while you are taking it, talk to your doctor straight away if:

• your body does not absorb vitamin B12 (cobalamin) very well

medicines.org.uk/emc/files/...

Though how a patient would know their body doesn't absorb B12 well - or what that even means - is questionable.

I don't think it unreasonable to expect a pharmacist to at least once have read the SPC & PIL for products they frequently dispense.

[doityourself in reply to helvella]

I know Helvella but sadly I was only mildly surprise by the pharmacist s reply.

[FlipperTD in reply to doityourself]

To be honest I'm more disappointed in the Pharmacist than I would be with the average GP. I know some GPs who are very much clued up on B12 issues, but clearly not all of them. I suspect that some of the 'Professionals' [note the inverted commas!] if they've had a close relative involved. Then, all of a sudden, they read up and learn. As for the tide of ignorance, keep swimming. A long-distance, slow crawl should do it.

Keep the faith!

[doityourself in reply to FlipperTD]

🤣🤣🤣Agreed

[Jillymo in reply to FlipperTD]

Oh heck Flipper I am on PPIs but cant swim ! 🏊

HELP I am sinking.

Armbands anyone ? ? ?

[FlipperTD in reply to Jillymo]

Options are

Swimming lessons, or simply turn on your back and stretch your arms out to the sides. You'll float. If you lift them up, your body sinks, so don't do that. The Dead Sea is so saline you can't sink in it but trips to Israel are beyond my generosity. PPIs and B12 injections are a good combination, like 'Pie and Peas'. [well, not that much like Pie and Peas, but it's got PP in it.]

[Sleepybunny]

Hi,

I hope your mum gets the treatment she needs.

Do you mind me asking which country she is in?

The reason I'm asking is that patterns of treatment for B12 deficiency vary between countries, type of B12 used can vary and it might help forum members to post the most relevant info.

UK links that mention B12 deficiency and PPIs

B12 deficiency is listed as a potential long term side effect of omeprazole in link below.

nhs.uk/medicines/omeprazole...

Article from Pulse magazine

pulsetoday.co.uk/news/clini...

If you search online for "b12 deficiency PPI" that should show more articles.

I'm not medically trained.

[Rexz]

I certainly agree with Hypopotamus and Flipper’s comments. Here’s some additional STUFF OK, firstly, I apologize for my rambling diatribe below but hopefully there is something useful for you in there. Secondly, YES, Daily long-term use of PPIs (e.g., longer than 3 years) may lead to malabsorption or a deficiency of Vitamin B12 and in my simply uneducated opinion anyone on long term PPI should also be receiving B12 injections.

I’m certainly no doctor but after being prescribed Omeprazole myself back in 2020 just as I was diagnosed with PA, I did a lot of research. I ended up taking one capsule and never took the rest. I went and had my stomach acid tested during my second stomach cancer screening and low and behold my measured PH was 6 which mean neutral acidity or pretty much NO stomach acid. Since then, I now take stomach acid supplements and digestive enzymes before each meal which solved a lot of my digestion issues.

It is known that low stomach acid (Hypochlorhydria) is a major cause of acid reflux, but doctors prescribe PPIs anyway. Without knowing the cause of the acid reflux. It may be too high, to low, or a malfunctioning esophageal sphincter etc.

My initial thought on PPI is that PPIs are not good for you long term and may actually exacerbate a problem like low stomach acid or Hypochloridria condition. My suggestion is that anyone on long term PPI use receive B12 injections as a minimum and that doesn’t begin to address all the other potential malabsorption issues.

PPIs reduce the production of acid by the stomach. They work by irreversibly blocking an enzyme called H+/K+ ATPase which controls acid production. This enzyme is also known as the proton pump and is found in the parietal cells of the stomach wall.

PPIs treat conditions that are caused by either an overproduction of stomach acid or exacerbated by stomach acid. Taking a PPI once a day inhibits around 70% of proton pumps, so a small amount of acid is still available for food digestion.

The thing I find curious regarding diagnosis of acid reflux and the arbitrary prescribing of PPIs treatment is this.

1. The medical community all agree that GORD, GERD are caused by gastric acid reflux or acid splashing up through the open or partially open Lower Esophageal Sphincter.

2. But then they automatically prescribe a PPI to reduce the stomach acid without knowing or ever testing for stomach acid levels? Is it high? Is it low? Is it normal? Is there some other reason that the Esophageal Sphincter is not closing properly? None of these questions does the clinician ask of himself.

3. Clinicians assume that gastric acid reflux is caused by acid levels being too high in the stomach, but they do not consider that it can and most likely, especially in the elderly population, be caused by too little or low stomach acid in the stomach.

4. Why then do they treat with PPIs without ever testing for stomach PH? Would this not be a determinant in finding true root cause?

This is from UK National Institute for Health and Care Research NIHR

“When taken for a long time, side effects from PPIs can be serious, including an increased risk of bone fractures.”

evidence.nihr.ac.uk/alert/t...

One thing I highly suggest is that you not stop your PPIs on your own. But to talk to your GP about all of your concerns and then if you decide to come off of PPI then to be weaned off them slowly. Here is an excerpt from a 2017 published report by U.S. Pharmacists “Proton Pump Inhibitors: Considerations with Long-Term Use”.

Hypergastrinemia

“Gastric acid suppression leads to hypergastrinemia. This condition causes rebound hyperacidity; after discontinuing PPI therapy, patients may experience worsening GERD symptoms. This course of therapy can be as short as 8 weeks.2,3 To avoid this, PPIs should be slowly tapered. In addition, hypergastrinemia can cause parietal cells to hypertrophy and enterochromaffin-like cells (ECL) to undergo hyperplasia.3,6 These effects may increase the risk for gastric cancer, but this relationship has mostly been observed in vitro; however, a case study has recently been published describing the first case of ECL cell–derived neuroendocrine carcinoma as a result of hypergastrinemia secondary to more than 15 years of PPI usage.2,7 Despite this, evidence does not support an increased risk of cancer in patients using PPIs.2,6,8”

It’s a good idea to read the whole report as there is discussion on other issues with long term use.

uspharmacist.com/article/pr...

An excerpt from Gastroenterology “Evidence That Proton-Pump Inhibitor Therapy Induces the Symptoms it Is Used to Treat”

gastrojournal.org/article/S...

The “liberal employment of proton-pump inhibitor therapy has been recommended recently by many national and international guidelines based on “number needed to treat” and health economic analyses.12, 13 As a consequence, a substantial proportion, if not majority, of patients now prescribed proton-pump inhibitor therapy do not have acid-related symptoms and therefore have no true indication for such therapy. The current finding that these drugs induce symptoms means that such liberal prescribing is likely to be creating the disease the drugs are designed to treat and causing patients with no previous need for such therapy to require intermittent or long-term treatment. It is likely also that treatment of mild reflux symptoms with such therapy may aggravate the underlying disease and lead to an increased requirement for long-term therapy. Studies are required to investigate whether early treatment of mild reflux disease with proton-pump inhibitor therapy results in aggravation of the natural history of the condition.”

Here are some additional references you can peruse.

Proton Pump Inhibitor Nonresponders

gastroenterologyandhepatolo...

Can achlorhydria mimic symptoms of acid reflux? How often is it misdiagnosed?

answers.zocdoc.com/details/...

The impact of proton pump inhibitors on the human gastrointestinal microbiome

ncbi.nlm.nih.gov/pmc/articl...

A case of Barrett’s esophagus in pernicious anemia: acid is not the only culprit!

journals.sagepub.com/doi/fu...

The Myth of GERD: It’s Not the Acid, Stupid!

drreebs.com/the-myth-of-ger...

PPIs and GERD

youtube.com/watch?v=MALUXp6...(Not working as expected?)

[wedgewood in reply to Rexz]

Excellent video —Thanks.

[Technoid in reply to Rexz]

Great info.

[Treesong2023 in reply to Rexz]

That reply was ...just excellent. Sleepybunny, as ever, thank you.

Rexz, your reply was super packed with really helpful and useful information and explanation. It explains a whole lot to a long long term user of ppi's. Clearly, they have played a part in my medical problems.

It warms the cockles of my heart when I see the good good people in here trying to help others.

Thank you Rexz. 🌻. For your time, the sharing of your gathered "knowledge" and linkage of the aspects involved. Fab.

[doityourself in reply to Rexz]

Many thanks for that full, thorough and in my opinion highly accurate response.Video is great.

Thank you

[Chickens44 in reply to Rexz]

Can I ask, do you know how long it takes to get your stomach acid back to correct levels after stopping omeprazole. I was taking it for over 15 years and stopped at Christmas, but I am still suffering fatigue, brain fog, and many other symptoms, which I am putting down to malabsorption. I have just started taking Betaine Hydrochloride capsule to see if it helps.

[Rexz in reply to Chickens44]

Hi Chickens44

I'm not sure as 15 years is a very long time to be on PPI. I know that for short term use after stopping the acid secretion levels return fairly quickly like after a few days to a week in a healthy person.

The research on recovery from long term use is rather scant. I would suggest that you have your serum Gastrin tested, a simple blood test. That is a easy way to indirectly determine if you have too much or too little acid. If serum Gastrin is normal then you are most likely OK. If it is very high like up around 1,000 or more then you may have very little stomach acid. The fact that you are taking Betaine HCL and not experiencing acid reflux leads me to believe you may have low gastric acid. Personally I have achlorhydria or zero stomach acid so I have to take Betaine HCL and digestive enzymes before each meal. I think it good that you've stopped PPIs and you're not experiencing acid reflux. When you were first prescribed PPI was it a result of an endoscopy? or Gastroscopy? I'm not sure which country you are in. most gastroenterologists when they see Gastritis inflammation will automatically prescribe PPI. It is a flawed mentality but that could be why?

Please know I'm no doctor, but rather just a madman! 😂

Best wishes, Rexz

[Hidden]

I have been taking pantoprazole for some time. I have a large hiatal hernia, which causes silent reflux, croaky voice, sore throat, coughing, choking, swallowing issues. Not just heartburn in my case. Some time ago I felt I was low on B12. GP did a test and I was low. After loading injections, and a negative PA test, I started taking 2 B12 tablets per day. I have had a B12 test since then, and my levels now are ok, so have carried on taking them. I tried stopping the pantoprazole, and using Gaviscon to control the acid reflux. I had a lots of problems with coughing and choking along with other symptoms, and on advice from the speech and language therapist who was helping I am now back on 2 pantoprazole per day. It is fine to say PPIs are dangerous long term, and it is masking causes of heartburn. I know what the cause is, and I know the risks of silent reflux and its effects on the oesophagus. At present I don't see an alternative. I am on a waiting list to see an ENT specialist. It really depends on the reasons why the PPI is being prescribed, and the risks of not taking it, but obviously B12 needs checking.

[Treesong2023 in reply to Hidden]

From what we read above on PPI's, absorption checks, and a check of acid / alkaline levels might well be helpful as well as B12 angle?

[Dylfan]

Hi Blondie51As well as the above valuable advice and info l would add my tuppence worth briefly.

Having had major problems with long-term ppis probably causing suppression of gastric acid and consequential prevention of absorption of magnesium, copper, calcium etc .

I found taking a multivitamin helped reverse some of my symptoms rapidly .

Good Luck