Be aware of possible PPI complications that can affect health

Q: More and more evidence suggests that long-term use of PPIs is bad for health. I've read they contribute to osteoporosis, C. diff, pneumonia, vitamin deficiencies and other problems.

There are 30 million people in the U.S. taking these drugs long term. It is an epidemic. How can we change this?

A: You're quite right that proton-pump inhibitor (PPI) medicines such as esomeprazole (Nexium), omeprazole (Prilosec) and pantoprazole (Protonix) have been linked to a higher risk of hip fractures (Annals of Epidemiology, April 2014).

Other complications of PPIs include significantly greater risks of developing pneumonia, Clostridium difficile (C. diff) infection and magnesium, iron or vitamin B-12 malabsorption, as well as a blood disorder called thrombocytopenia that may lead to excessive bleeding (Expert Review of Clinical Pharmacology, July 2013). Both patients and prescribers should be aware of these hazards, so that the drugs are used only when necessary and for the shortest possible time.

Q: Recently, my husband took tramadol after back surgery. He also was taking an SSRI antidepressant.

He suffered severe hallucinations and sleep-talking throughout the night. The emergency-room doctor suspected serotonin toxicity from the combination of tramadol and the SSRI. It took almost a week for him to get back to normal.

A: Because tramadol is considered a pain medication, doctors sometimes don't think of it as interacting with serotonin-based antidepressants such as citalopram or fluoxetine to cause serotonin syndrome (American Journal of Case Reports, Dec. 19, 2014). Several case reports of such interactions have been published.

Symptoms of serotonin syndrome include agitation, confusion, high blood pressure, rapid heart rate, muscle twitching, shivering, headache and diarrhea. Severe cases can result in high fever, unconsciousness or even death.

Q: I have read that milk can neutralize the flavonoid compounds that make cocoa or chocolate healthful. How does that work? Is soy milk just as problematic? I want to get the maximum benefit from my pricey cocoa powder.

A: The protein in milk can form complexes with the flavonoid compounds in cocoa or those in tea (Journal of Agricultural and Food Chemistry, July 27, 2011). However, this does not seem to affect how much of the flavonoids are absorbed; one study showed no significant difference in blood levels whether 21 volunteers drank their cocoa made with milk or made with water (Annals of Nutrition and Metabolism, February 2008).

You could use rice milk as a substitute for cow's milk. It is very low in protein and probably would have little or no impact on the cocoa.