Heartburn and COVID-19: Q&A With Kyle Staller, MD, MPH

Proton pump inhibitors (PPIs) are the most widely used heartburn medication, and for good reason: They are the strongest available option for stopping acid production at its source. But recent headlines highlight survey findings (published in the American Journal of Gastroenterology) that indicate an increased risk of COVID-19 among PPI users. But if you have heartburn does it mean you're at a higher risk for COVID-19?

According to Kyle Staller, MD, MPH, director of the Gastrointestinal Motility Laboratory at the Massachusetts General Hospital Division of Gastroenterology and gastroenterologist/neurogastroenterologist in the Swallowing and Heartburn Center, these findings aren't necessarily cause for alarm. In this Q&A, Dr. Staller explains the COVID-19-heartburn connection, and shares his expertise on the safety of PPIs.

Q: Do this study's findings mean PPIs increase a patient's risk of severe COVID-19 symptoms?

Staller: This was an observational study, meaning researchers aren't giving some people the drug and seeing what happens to those people versus what happens to the people who don't take it. Instead, it's comparing two different groups of people: A group of people with symptoms who happen to be taking the drug, and a group of people who don't.

On average, people who happen to be taking PPIs are likely to be a little bit sicker. It's not that these people are compromised by their heartburn medication; but rather that their heartburn is the result of being overweight, or suffering an ailment associated with an unhealthy lifestyle—something that puts them in a high-risk group. That's probably what's driving the risk for COVID-19.

Studies like this give us a better understanding of all the ways COVID-19 might infect the GI tract or the body in general. PPIs have their issues, but they're still an incredibly effective therapy. So while PPIs shouldn't be added to the water supply—meaning these drugs are not for everyone—there are people who derive a great benefit from PPIs, and we shouldn't scare them away.

Q: Why would these researchers choose PPIs over other heartburn treatments?

Staller: PPIs are very convenient because they're so commonly used. So if you do a study, your likelihood of finding something statistically significant is higher, because a good chunk of any population will be on PPIs. If you pick something rarer, you're less likely to see an effect.

Interestingly, they did look at over-the-counter (OTC) H2 blockers, and found that there was not an associated risk of COVID-19. For the most part, people who take OTC H2 blockers tend to take them infrequently and in response to acute heartburn. In other words, they aren't necessarily part of a group that is already at high risk.

As previously mentioned, PPIs are the most effective acid blockers. H2 receptors don't make your stomach quite as basic as PPIs do. If your stomach is less acidic, there is a chance that bugs (bacteria and viruses) can make it into your system. We know that's the case for some other types of infections—while COVID-19 is not a bacteria, we know there are bacteria you can swallow that could make you sick. So, there could be a more legitimate connection between PPIs and getting those kinds of infections than some of the other connections that we've seen reported in the news and literature.

PPIs may also decrease the "infectious dose," or the amount of bacteria or virus you would need to be exposed to to get sick. Certain diseases require a large infectious disease dose; for example, you need to drink a good deal of water to contract cholera. Meanwhile, you only have to ingest a small amount of norovirus to get sick. PPIs may decrease the dose of virus that you need to get sick, because they eliminate the stomach acid (i.e. the barrier).

Of course, this is all hypothesis. And there are problems with the studies connecting COVID-19 to PPIs that are important to remember when we think about this connection.

Q: What would you recommend to people worried about the risks of PPIs?

Staller: It mostly comes down to absolute versus relative risk. For several years, we've seen people inappropriately stopping their PPIs because they're concerned about kidney disease or dementia—or, now, COVID-19. In reality, it's a balance of risks and benefits. The absolute risk is quite small, but the relative risk—which is often how they measure these things in most articles—might say you're three times more likely to develop COVID. It's important to consider the fact that if your absolute risk is very low, when you multiply it by three, it's still relatively low.

Think of it like the lottery: If you buy two lottery tickets, you are twice as likely to win, but your absolute risk of winning is still low enough that you're probably not going to quit your job. By that same logic, if you don't have to take a PPI, there's no need to start. But if you do have to take one, your absolute risk is still pretty low.

Q: What steps should people on PPIs take to stay safe from COVID-19?

Staller: Wearing a mask and physical distancing are much more effective against COVID-19 than anything you can do with your PPI. If you continue taking your PPI and adhere to preventative measures, you can live a healthier, heartburn- and COVID-19-free life.

The take-home message is this: All medicines have potential risks. The risk for PPI is not zero, but it's incredibly low. If you don't need PPIs, you shouldn't be taking them. However, if you do, you should be taking the lowest possible dose. But if you've been struggling with heartburn for a while, you are deriving more of a benefit from PPIs than you would from stopping them.

In other words: if you are currently prescribed PPIs, don't stop taking them.