When a recent study found that a popular class of heartburn drugs might weaken bones, Dorothea E. Kilner was alarmed, but not just because her medication could contribute to a hip fracture.
For Kilner and the millions of Americans who suffer from chronic heartburn, the greater threat may be losing access to prescription drugs such as Prevacid, Prilosec, Protonix and Nexium. They're far more effective than earlier generations of heartburn medication, according to doctors and to patients who rely on them for relief.
"The real question is, what's the other choice?" said Dr. David B. Posner, chief of gastroenterology at Mercy Medical Center. "Most people who take these drugs know that once they stop taking them their pain is going to come back."
Kilner has already made up her mind. "I'm going to continue taking my Nexium because it works for me," said the 72- year-old Timonium resident. "The quality of life has improved for me by taking it."
Posner said the benefits of these drugs, known as proton pump inhibitors, or PPIs, outweigh the risks. While the study results announced Dec. 27 suggested that older people who take the drugs might want to take extra precautions to prevent bone loss, the link between hip fractures and the drugs is inconclusive, he said.
"There is no drug which is free of side effects," he said. "The over-the-counter drugs work fairly well but not nearly as well as this class."
Posner drew an analogy to the pain medication Vioxx, which was pulled from the market in 2004 after it was linked to an increased risk of heart attack and stroke. "It's the same thing as people saying that Vioxx worked so well they were willing to take the risk," he said.
Most people never need prescription drugs for heartburn, also known as acid indigestion. It results from acidic stomach juices leaking (or refluxing) through a muscular valve back into the esophagus, the tube through which food passes from the pharynx to the stomach.
The acid irritates the lining of the esophagus, causing a burning sensation in the chest and throat.
Heartburn is often caused by bending over or lying down, especially after eating a big meal. Other aggravating factors include pregnancy, obesity, tight clothing, citrus fruits, pain medications and a laundry list of vices, including cigarettes, coffee, alcohol, and fried and fatty foods.
Over-the-counter antacids such as Tums, Maalox and Pepto-Bismol neutralize the acidic stomach juices and are usually sufficient to provide relief for people who experience occasional heartburn.
But for many people, acid indigestion crosses the threshold from an occasional minor irritation to a chronic medical condition. According to the National Heartburn Alliance, more than 50 million Americans suffer from heartburn at least twice a week. Those that seek treatment are typically diagnosed with gastroesophageal reflux disease, or GERD, also commonly referred to as acid reflux disease.
In addition to the burning sensation, GERD can cause a nagging cough, asthma, difficulty swallowing and ulcers in the esophagus. It also increases a person's chances of developing esophageal cancer.
"It's horrible," said Anne E. Horner, 59, who was diagnosed with GERD three years ago. "I was waking up in the middle of the night and feeling like I was going to vomit."
The Sparks resident now takes Nexium, which relieves her symptoms. "The benefit has been far greater than any risk," she said.
PPIs are highly effective at preventing serious damage to the esophagus and easing patients' symptoms, doctors said.
The drugs work by blocking the action of tiny pumps on the outside of cells lining the stomach. By preventing the cells from releasing gastric acid, the drugs make the fluids leaking into the esophagus less corrosive.
Dr. Lisa S. Pichney, a gastroenterologist at St. Joseph Medical Center who treats Kilner, said the number of her patients who have GERD has increased in the past five years.
So, too, has the sale of PPIs, which are among the most widely prescribed drugs in the United States. Sales of Nexium alone were about $4.6 billion in 2005.
Pichney attributed this to a growing awareness that effective medicines are available and that chronic reflux can lead to more serious problems. "For many patients, it's not satisfactory to use over-the-counter drugs," she said.
"They are miserable. They think they are having heart attacks," Pichney said, referring to stabbing pains that can be similar to angina. "It's chronic, and it's relapsing."
She said the recent study, which was published in The Journal of the American Medical Association, was not sufficient reason for her to stop prescribing the drugs.
The study was conducted by researchers at the University of Pennsylvania School of Medicine, who used a large British database to identify 13,566 hip fracture patients over the age of 50 and a matched group of 135,386 healthy people.
They found that taking the drugs for a year increased the risk of hip fractures by 44 percent. Patients who took high doses of the drugs - the equivalent of two pills a day - were up to 2.6 times more likely to suffer a fracture.
The study's authors suggested the drugs may have prevented the patients from absorbing enough calcium. But they acknowledged that their results needed to be confirmed by more rigorous studies. Meanwhile, they urged physicians to prescribe the lowest possible dose and use the drugs only on patients who really need them.
Dr. Ibrahim A. Razzak, chief of gastroenterology at Greater Baltimore Medical Center, agreed that doctors should work with patients to pinpoint the exact dose they need. "I always tell my patients to ... take the smallest doses possible," he said.
He also suggests his patients make sure to get enough calcium, preferably through eating calcium-rich foods. Patients could also undergo bone density scans to determine whether they are at risk of fractures, he said. Other precautions to safeguard bones include engaging in weight-bearing exercise, getting enough Vitamin D and minimizing the chance of falling.
Kilner, who developed chronic heartburn 25 years ago and also has osteoporosis, cut back on chocolate and Italian food, with its acidic tomato sauces. "I also limit myself to coffee once a week, which is a stretch for me," she said. Yet she still gets the burning sensation in her throat and the bitter taste in her mouth.
She's also had two friends die of esophageal cancer.
The risks of taking heartburn medicine don't faze her.
"We're not all here permanently anyway," she said. "We have to do the best with what we've got."