How To Wean Off Your Acid Suppressing Drugs-Part 3

A bunch of purple medication pills

Are you taking an acid suppressing drug to help control your heartburn such as Nexium, Prilosec, Prevacid, or Protonix? These drugs are called Proton Pump Inhibitors (PPIs). Proton Pump Inhibitors (PPIs) are medications that reduce stomach acid secretion to control symptoms of gastroesophageal reflux disease (GERD). I mentioned in the previous post Five Reasons Why You Need Stomach Acid, how powerful these drugs are at reducing stomach acid, ranging from 84-100% inhibition. Maybe you have been on these drugs for many years and you want to try diet and lifestyle changes rather than relying on a PPI to give you symptom relief. This is a good idea, because even the FDA is now issuing warnings about the long term use of PPIs due to increased incidences in bone fractures, micronutrient deficiencies, and bacterial infections (see FDA.gov for more information).

If you are already taking a PPI, then you will need to have a discussion with your healthcare provider to determine if you are a candidate for weaning off of your medication. PPIs have their time and place and it is important to make sure that you do not have a condition that would necessitate the need to continue a PPI (in order to heal erosive esophagitis or an ulcer, for example). Once you have the OK from your healthcare provider, you will need to slowly taper the dosage while you are making the diet and lifestyle changes (see “Adjust your Diet and Lifestyle, Mindful Eating and Supplement Support) in the post Simple Steps To Treat Heartburn And Reflux Naturally.

DO NOT abruptly stop taking a PPI or you can have rebound hyperacidity (37). This is why it is so difficult to stop a PPI, because reflux can actually worsen due to a large increase or rebound in stomach acid production that occurs when abruptly stopping a PPI. Go slowly and work with your healthcare provider to adjust the dosage to taper over a 4 week period. When you are at the lowest tapered dose, then start an over the counter H2 blocker like Pepcid AC, Tagemet HB or Zantac. These suppress acid by a different mechanism and are not as strong as a PPI. Once you feel like your symptoms are under control, then stop the PPI and start gradually weaning off of the H2 blocker over 2-3 weeks.

Replace Your Stomach Acid

If you have been on a PPI for long term, then your stomach acid will be very low and you will need to replace it once you stop the acid suppressing drug. If you are suffering from heartburn symptoms and want to treat them naturally, getting your stomach acid levels tested could be very helpful. Remember from a previous post in this series, according to Dr. Jonathan Wright, a physician who has measured stomach acid in countless individuals with GERD, approximately 90% of the patients tested had low stomach acid, not too much stomach acid (17). A test called the Heidelberg Capsule Test can be done in an office setting and is the gold standard to measure stomach acid. If you don’t have access to this test, a low tech way to determine if you need more stomach acid is to do a trial of betaine HCl.

Betaine HCl is a supplement used to deliver hydrochloric acid. According to the PDR for Nutritional Supplements, 2nd edition (2008), betaine HCL has been used as a digestive aid for people who have hypochlorhydria (low stomach acid). Dr. Wright says that this supplement is extremely effective in eliminating heartburn, however, it is not without risks. He recommends that betaine HCl should not be taken if you are taking any of these medications:

  • Anti-inflammatory medications like aspirin, ibuprofen, corticosteroids (like prednisone), Indocin, or other NSAIDS. These medications are known to irritate the stomach lining and increase risks of ulcers. You would not want to irritate an already irritated stomach lining by taking betaine HCl.

How To Supplement With Betaine HCl

Betaine HCl is sold in approximately 650 mg capsules and should always be accompanied with pepsin. Pepsin is an enzyme activated in the stomach by stomach acid. Do not purchase a brand of betaine HCl if it does not also contain pepsin or it will not be as effective. Betaine HCl should only be taken with meals that contain protein. The more protein you eat at a meal, the more betaine HCl you will need to take. First, while you are experimenting with your betaine HCl dosage, try to keep your protein intake consistent until you know how much you need to take. Most people eat about 3-4 oz of protein with each meal. Three ounces of meat looks like a deck of cards or the palm of your hand (excluding your fingers), a 3 ounce serving of fish is about the size of a check book and 3 eggs equals 3 ounces. Here is a betaine HCl protocol recommended by the authors of the website: SCDLifestyles (38):

  1. “Start by taking 1 pill (650mg or less) of betaine HCl during the beginning of the meal. Finish the meal as normal and observe your body for any changes in feeling associated with the stomach and belly button area. Things to look for: heaviness, hotness, burning, or other GI distress.
  2. Stay at this dosage of 1 pill for another day of meals with protein and if you don’t notice anything on the 3rd day, try 2 pills.
  3. Stay there for another day and then try 3 pills.
  4. Keep increasing the number of pills taken with each meal until you notice some GI discomfort described in step #3.
  5. When this happens, you will know your ideal betaine HCl dosage is 1 pill less. For example, if you felt the discomfort going from 5 pills to 6 pills, then 5 pills is your proper dosage for a normal meal.”

According to Dr. Wright, the most effective dose of betaine HCl is between 5-7 capsules per meal. That sounds like a lot, but when your stomach is working properly, it will produce much more acid then what is provided by the 5-7 capsules. By following the above protocol and doing some experimentation, you will find your effective dose.

You may be asking, do I have to take betaine HCl forever? And my answer to you is hopefully not, once you make the diet and lifestyle changes, address dysbiosis, and get off of the PPIs, your stomach acid levels should return to normal. However, I have heard that some people may need to take betaine HCl indefinitely. We know that as we age, stomach acid levels decrease naturally and the need for extra support might be required.
If you are unsure as to whether you can take betaine HCl safely, then you can start with Swedish bitters, which was mentioned in the post Simple Steps To Treat Heartburn And Reflux Naturally. Bitters will help stimulate your digestive juices. Another thing that you can do is try apple cider vinegar, 1-2 T in 4 oz of water 15 minutes before every high protein meal or when you feel the first signs of reflux. It is not as pleasant as taking betaine HCl capsules, but it can be very helpful and it has been used for millennia to treat GERD. The unfiltered, organic brand like Braggs is recommended.

Get Tested For Gut Infections

If you are still having problems after making the suggested changes in this series on GERD, then you should consider getting tested for an infection. Gut infections can cause an imbalance in your healthy gut flora and lead to dysbiosis throughout the intestinal tract. It is important to identify and treat gut infections in order to restore your beneficial bacteria and heal the mucosal lining of your intestinal tract. Here are some recommended tests:

H. pylori

Helicobacter pylori (H. pylori) infects approximately 50% of the world population. Ninety percent of ulcers are caused by this bacterium. In order to ensure its survival, it reduces stomach acid secretion. You might think this is a good thing-less stomach acid, less GERD; and in fact, some studies indicate that GERD increases when eradicating H. pylori. However, remember, low stomach acid can increase bacterial overgrowth and cause all of the problems mentioned in this previous post Five Reasons Why You Need Stomach Acid. This is why it is important to make all of the recommended diet and lifestyle changes in addition to treating an H. pylori infection (39). PPI use may mask H.pylori infection (40), so it is important to get tested. Most integrative practitioners believe that if H. pylori infection is positive, then it is important to eradicate it to normalize stomach acid secretion. There are several ways to test for H. pylori and these options will vary between practitioners.

SIBO

Small intestinal bacterial overgrowth (SIBO) is a condition where microorganisms that should be contained in the large intestine, populate the small intestine in larger numbers than what is normal. This can cause a host of symptoms, including bloating, constipation, diarrhea, upset stomach and extra-intestinal symptoms as well-ranging from acne rosacea to rheumatoid arthritis. Quite a few studies show that PPIs cause SIBO (41, 42); however, some studies are inconclusive (43). A large number of people with irritable bowel syndrome (IBS) suffer from GERD. One study published in 2012 estimated that people with IBS were 4 times as likely to suffer from gastroesophageal reflux type symptoms (44) while a study published in 2014 found that 64% of people who had IBS also had GERD (45). This study also noted that GERD patients had a higher incident of H. pylori infection. It is important to note that there is an overlap in IBS and GERD, indicating that these two functional gastrointestinal issues are related. In addition, it is estimated that a large number of people with IBS have SIBO, and that SIBO may be the cause of IBS. The point is, all of these conditions are associated with an altered microbiome. Breath hydrogen testing is the most common, non-invasive means of measuring SIBO.

Parasites

Parasitic infections are not thought to be a problem in the United States, but many integrative practitioners test and find parasitic infections in people who have not traveled outside of the US. A study published in The American Journal of Tropical Medicine and Hygiene found that “one-third of 5,792 fecal specimens from 2,896 patients in 48 states and the District of Columbia tested positive for intestinal parasites during the year 2000” (46). One of the reasons that parasitic infections may be a problem in the US is our global environment. You don’t have to travel outside of the US to come into contact with people who are infected. Parasitic infections can be contracted from infected people through various means-like eating food prepared by someone who is infected and didn’t wash their hands. In addition, people who suffer from chronic health conditions may have a depressed immune system, making it easier to contract a parasitic infection. Parasitic infections can lead to dysbiosis and need to be eradicated to restore the gut microbiome. Stool testing using various technologies (microscopy, DNA-PCR) can be utilized to detect a parasitic infection.

Dysbiosis

There is a convincing association between an altered microbiome (dysbiosis) and reflux disease (47). By following the suggested strategies to naturally treat GERD-see previous post Simple Steps To Treat Heartburn And Reflux Naturally, and by treating any gut infections that may be present, dysbiosis should resolve.

In conclusion, it is imperative that the normal physiologic digestive processes are restored, proper diet and lifestyle changes are adopted, and any identified gut infections are eradicated to end GERD naturally.

References for Series on GERD
1. InsognaKL. The effect of proton pump inhibiting drugs on mineral metabolism: Am J Gastroenterol. 2009; 104 Suppl 2:S2-4.
2. Marcuard S. Omeprazole therapy causes malabsorption of cyanocobalamin (Vitamin B_12):Annals of Internal Medicine. 1994;120(3):211. doi:10.7326/0003-4819-120-3-199402010-00006.
3. Jacobs A, Lawrie J, Entwistle C, Campbell H. Gastric acid secretion in chronic iron-deficiency anaemia:. The Lancet. 1966;288(7456):190-192. doi:10.1016/s0140-6736(66)92475-5.
4. Krasinski S, Russell R, Samloff I, et al. Fundic atrophic gastritis in an elderly population: effect on hemoglobin and several serum nutritional indicators:Journal of the American Geriatrics Society. 1986;34(11):800-806. doi:10.1111/j.1532-5415.1986.tb03985.x.
5. Marcuard S. Omeprazole therapy causes malabsorption of cyanocobalamin (Vitamin B12):Annals of Internal Medicine.1994;120(3):211. doi:10.7326/0003-4819-120-3-199402010-00006.
6. Russel R, Golner B, Krasinski S, Sadowski J, Suter P, Braun C. Effect of antacid and H2 receptor antagonists on the intestinal absorption of folic acid:J Lab Clin Med [Internet].1988[cited 2015 Dec 15];112(4):458-63. Available from: http://www.ncbi.nlm.nih.gov/pubmed/2902178.

7. Ivanovich P. The absorption of calcium carbonate: Annals of Internal Medicine. 1967;66(5):917. doi:10.7326/0003-4819-66-5-917.

8. Henderson L, Brewer G, Dressman J, et al. Effect of intragastric pH on the absorption of oral zinc acetate and zinc oxide in young healthy volunteers:Journal of Parenteral and Enteral Nutrition. 1995;19(5):393-397. doi:10.1177/0148607195019005393.
9. Saltzman JR, Kemp JA, Golner BB, et al. Effect of hypochlorhydria due to omeprazole treatment or atrophic gastritis on protein bound vitamin B12 absorption:J AmerCollNutr1994;13:584-591.
10. Lombardo L, Foti M, Ruggia O, Chiecchio A. Increased incidence of small intestinal bacterial overgrowth during proton pump inhibitor therapy:Clinical Gastroenterology and Hepatology. 2010;8(6):504-508. doi:10.1016/j.cgh.2009.12.022.
11. Theisen J. Suppression of gastric acid secretion in patients with gastroesophageal reflux disease results in gastric bacterial overgrowth and deconjugation of bile acids: Journal of Gastrointestinal Surgery. 2000;4(1):50-54. doi:10.1016/s1091-255x(00)80032-3.
12. Lee H, Pimentel M. Bacteria and irritable bowel syndrome: The evidence for small intestinal bacterial overgrowth: Current Gastroenterology Reports. 2006;8(4):305-311. doi:10.1007/s11894-006-0051-3.
13. Tennant S, Hartland E, Phumoonna T, et al. Influence of gastric acid on susceptibility to infection with ingested bacterial pathogens:Infection and Immunity. 2007;76(2):639-645. doi:10.1128/iai.01138-07.
14. Marcum Z, VandeGriend J, Linnebur S. FDA drug safety communications: a narrative review and clinical considerations for older adults: The American Journal of Geriatric Pharmacotherapy. 2012;10(4):264-271. doi:10.1016/j.amjopharm.2012.05.002.
15. Vesper B, Jawdi A, Altman K, Haines III G, Tao L, Radosevich J. The effect of proton pump inhibitors on the human microbiota: CDM. 2009;10(1):84-89. doi:10.2174/138920009787048392.
16. Singer M. Pancreatic secretory response to intestinal stimulants: a review:Scand J Gastroenterol. 1987;22(s139):1-13. doi:10.3109/00365528709089768.
17. Wright J, Lenard L. Why stomach acid is good for you. New York: M. Evans; 2001.
18. Kresser, Chris. The hidden cause of heartburn and GERD [Internet]. 2010. Available from: http://chriskresser.com/the-hidden-causes-of-heartburn-and-gerd/
19.Yang, et al. Inflammation and intestinal metaplasia of the distal esophagus are associated with alterations in the microbiome: Gastroenterology. 2009;137:588-597.
20. Austin G, Thiny M, Westman E, Yancy W, Shaheen N. A very low-carbohydrate diet improves gastroesophageal reflux and its symptoms: Dig Dis Sci. 2006;51(8):1307-1312. doi:10.1007/s10620-005-9027-7.
21. Yancy W, Provenzale D, Westman E. Improvement of gastroesophageal reflux disease after initiation of a low-carbohydrate diet: five brief case reports: Altern Ther Health Med [Internet]. 2001 [cited 2015 Dec 15];7(6):120, 116-9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11712463.
22. Piche T, des Varannes SB, Sacher-Huvelin S, Holst JJ, Cuber JC, Galmiche JP. Colonic fermentation influences lower esophageal sphincter function in gastroesophageal reflux disease: Gastroenterology. 2003 Apr 30;124(4):894-902.
23. Taché Y, Martinez V, Million M, Wang III, L. Stress-related alterations of gut motor function: role of brain corticotropin-releasing factor receptors: American Journal of Physiology-Gastrointestinal and Liver Physiology. 2001 Feb 1;280(2):G173-7.
24. Pellegrini CA. Delayed gastric emptying in patients with abnormal gastroesophageal reflux: Annals of surgery. 2001 Aug;234(2):147.
25. Herman JH, Nolan DS. A bitter cure: New England Journal of Medicine. 1981;305(27):1654-1654. doi:10.1056/nejm198112313052724.
26. Glick L. Deglycyrrhizinated liquorice for peptic ulcer: The Lancet. 1982;320(8302), 817.
27. Tewari S, Trembalowicz F. Some experience with deglycyrrhizinated liquorice in the treatment of gastric and duodenal ulcers with special reference to its spasmolytic effect: Gut. 1968;9(1):48-51. doi:10.1136/gut.9.1.48.
28. Hayakawa A, Inoue M, Kunizaki M, et al. Clinical evaluation of Z-103 on gastric ulcer: Jpn Pharm Ther 1992;20(1):1-18.
29. Miyoshi A, Matsuo H, Miwa T, et al. Clinical evaluation of Z-103 in the treatment of gastric ulcer: a multicenter double-blind dose finding study: Jpn Pharm Ther 1992;20:181-97
30. Hiraishi H, Sasai T, Oinuma T, et al. Polaprezinc protects gastric mucosal cells from noxious agents through antioxidant properties in vitro: Aliment Pharmacol Ther. 1999;13:261-269
31. Yanase K, Funaguchi N, Iihara H, Yamada M, Kaito D, Endo J, Ito F, Ohno Y, Tanaka H, Itoh Y, Minatoguchi S. Prevention of radiation esophagitis by polaprezinc (zinc L-carnosine) in patients with non-small cell lung cancer who received chemo radiotherapy: International journal of clinical and experimental medicine. 2015;8(9):16215.
32. van der Hulst RR, Von Meyenfeldt MF, Deutz NEP, Soeters PB, Brummer RJM, von Kreel BK, Arends JW. Glutamine and the preservation of gut integrity: The Lancet. 1993;341(8857), 1363-1365.
33. De-Souza D, Greene L. Intestinal permeability and systemic infections in critically ill patients: effect of glutamine: Critical Care Medicine. 2005;33(5):1125-1135. doi:10.1097/01.ccm.0000162680.52397.97.
34. Hu Y, Xu J, Hu Q. Evaluation of antioxidant potential of aloe vera (aloe barbadensis miller) extracts: J Agric Food Chem. 2003;51(26):7788-7791. doi:10.1021/jf034255i.
35. Lee K, Weintraub S, Yu B. Isolation and identification of a phenolic antioxidant from Aloe barbadensis. Free Radical Biology and Medicine. 2000;28(2):261-265. doi:10.1016/s0891-5849(99)00235-x.
36. Vogler B, Ernst E. Aloe vera: a systematic review of its clinical effectiveness: British Journal of General Practice [Internet]. 1999 [cited 2015 Dec 16];49:823-828. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1313538/pdf/10885091.pdf.
37. Niklasson A, Lindstrom L, Simren M, Lindberg G, Bjornsson E. Dyspeptic symptom development after discontinuation of a proton pump inhibitor: A double – blind placebo controlled trial: Am J Gastroenterol.2010 Jul;105(7) 1531-7.
38. How to supplement with betaineHCl for low stomach acid [Internet]. SCDLifestyles.[cited 2016 Jan 30]. Available from: http://scdlifestyle.com/2012/03/how-to-supplement-with-betaine-hcl-for-low-stomach-acid/.

39. Peek RM. Helicobacter pylori and gastroesophageal reflux disease: Curr Treat Options Gastroenterol.2004;7:59–70.

40. Nasser SC, Slim M, Nassif JG, Nasser SM. Influence of proton pump inhibitors on gastritis diagnosis and pathologic gastric changes: World Journal of Gastroenterology: WJG. 2015 Apr 21;21(15):4599.

41. Lombardo L, Foti M, Ruggia O, Chiecchio A. Increased incidence of small intestinal bacterial overgrowth during proton pump inhibitor therapy: Clinical Gastroenterology and Hepatology. 2010 Jun 30;8(6):504-8.
42. Theisen J, Nehra D, Citron D, Johansson J, Hagen JA, Crookes PF, DeMeester SR, Bremner CG, DeMeester TR, Peters JH. Suppression of gastric acid secretion in patients with gastroesophageal reflux disease results in gastric bacterial overgrowth and deconjugation of bile acids: Journal of Gastrointestinal Surgery. 2000 Feb 1;4(1):50-4.
43. Ratuapli SK, Ellington TG, O’Neill MT, Umar SB, Harris LA, Foxx-Orenstein AE, Burdick GE, DiBaise JK, Lacy BE, Crowell MD. Proton pump inhibitor therapy use does not predispose to small intestinal bacterial overgrowth: The American Journal of Gastroenterology. 2012 May 1;107(5):730-5.
44. Lovell RM, Ford AC. Prevalence of gastro-esophageal reflux-type symptoms in individuals with irritable bowel syndrome in the community: a meta-analysis: The American Journal of Gastroenterology. 2012 Dec 1;107(12):1793-801.
45.Yarandi SS, Nasseri-Moghaddam S, Mostajabi P, Malekzadeh R. Overlapping gastroesophageal reflux disease and irritable bowel syndrome: increased dysfunctional symptoms: World Journal of Gastroenterology: WJG. 2010 Mar 14;16(10):1232.
46. Amin OM. Seasonal prevalence of intestinal parasites in the United States during 2000: The American Journal of Tropical Medicine and Hygiene. 2002 Jun 1;66(6):799-803.
47. Yang L, Chaudhary N, Baghdadi J, Pei Z. Microbiome in reflux disorders and esophageal adenocarcinoma: Cancer Journal [Sudbury, Mass]. 2013 Dec;20(3):207-10.

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7. Ivanovich P. The absorption of calcium carbonate: Annals of Internal Medicine. 1967;66(5):917. doi:10.7326/0003-4819-66-5-917.
8. Henderson L, Brewer G, Dressman J, et al. Effect of intragastric pH on the absorption of oral zinc acetate and zinc oxide in young healthy volunteers:Journal of Parenteral and Enteral Nutrition. 1995;19(5):393-397. doi:10.1177/0148607195019005393.
9. Saltzman JR, Kemp JA, Golner BB, et al. Effect of hypochlorhydria due to omeprazole treatment or atrophic gastritis on protein bound vitamin B12 absorption:J AmerCollNutr1994;13:584-591.
10. Lombardo L, Foti M, Ruggia O, Chiecchio A. Increased incidence of small intestinal bacterial overgrowth during proton pump inhibitor therapy:Clinical Gastroenterology and Hepatology. 2010;8(6):504-508. doi:10.1016/j.cgh.2009.12.022.
11. Theisen J. Suppression of gastric acid secretion in patients with gastroesophageal reflux disease results in gastric bacterial overgrowth and deconjugation of bile acids: Journal of Gastrointestinal Surgery. 2000;4(1):50-54. doi:10.1016/s1091-255x(00)80032-3.
12. Lee H, Pimentel M. Bacteria and irritable bowel syndrome: The evidence for small intestinal bacterial overgrowth: Current Gastroenterology Reports. 2006;8(4):305-311. doi:10.1007/s11894-006-0051-3.
13. Tennant S, Hartland E, Phumoonna T, et al. Influence of gastric acid on susceptibility to infection with ingested bacterial pathogens:Infection and Immunity. 2007;76(2):639-645. doi:10.1128/iai.01138-07.
14. Marcum Z, VandeGriend J, Linnebur S. FDA drug safety communications: a narrative review and clinical considerations for older adults: The American Journal of Geriatric Pharmacotherapy. 2012;10(4):264-271. doi:10.1016/j.amjopharm.2012.05.002.
15. Vesper B, Jawdi A, Altman K, Haines III G, Tao L, Radosevich J. The effect of proton pump inhibitors on the human microbiota: CDM. 2009;10(1):84-89. doi:10.2174/138920009787048392.
16. Singer M. Pancreatic secretory response to intestinal stimulants: a review:Scand J Gastroenterol. 1987;22(s139):1-13. doi:10.3109/00365528709089768.
17. Wright J, Lenard L. Why stomach acid is good for you. New York: M. Evans; 2001.
18. Kresser, Chris. The hidden cause of heartburn and GERD [Internet]. 2010. Available from: http://chriskresser.com/the-hidden-causes-of-heartburn-and-gerd/
19.Yang, et al. Inflammation and intestinal metaplasia of the distal esophagus are associated with alterations in the microbiome: Gastroenterology. 2009;137:588-597.
20. Austin G, Thiny M, Westman E, Yancy W, Shaheen N. A very low-carbohydrate diet improves gastroesophageal reflux and its symptoms: Dig Dis Sci. 2006;51(8):1307-1312. doi:10.1007/s10620-005-9027-7.
21. Yancy W, Provenzale D, Westman E. Improvement of gastroesophageal reflux disease after initiation of a low-carbohydrate diet: five brief case reports: Altern Ther Health Med [Internet]. 2001 [cited 2015 Dec 15];7(6):120, 116-9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11712463.
22. Piche T, des Varannes SB, Sacher-Huvelin S, Holst JJ, Cuber JC, Galmiche JP. Colonic fermentation influences lower esophageal sphincter function in gastroesophageal reflux disease: Gastroenterology. 2003 Apr 30;124(4):894-902.
23. Taché Y, Martinez V, Million M, Wang III, L. Stress-related alterations of gut motor function: role of brain corticotropin-releasing factor receptors: American Journal of Physiology-Gastrointestinal and Liver Physiology. 2001 Feb 1;280(2):G173-7.
24. Pellegrini CA. Delayed gastric emptying in patients with abnormal gastroesophageal reflux: Annals of surgery. 2001 Aug;234(2):147.
25. Herman JH, Nolan DS. A bitter cure: New England Journal of Medicine. 1981;305(27):1654-1654. doi:10.1056/nejm198112313052724.
26. Glick L. Deglycyrrhizinated liquorice for peptic ulcer: The Lancet. 1982;320(8302), 817.
27. Tewari S, Trembalowicz F. Some experience with deglycyrrhizinated liquorice in the treatment of gastric and duodenal ulcers with special reference to its spasmolytic effect: Gut. 1968;9(1):48-51. doi:10.1136/gut.9.1.48.
28. Hayakawa A, Inoue M, Kunizaki M, et al. Clinical evaluation of Z-103 on gastric ulcer: Jpn Pharm Ther 1992;20(1):1-18.
29. Miyoshi A, Matsuo H, Miwa T, et al. Clinical evaluation of Z-103 in the treatment of gastric ulcer: a multicenter double-blind dose finding study: Jpn Pharm Ther 1992;20:181-97
30. Hiraishi H, Sasai T, Oinuma T, et al. Polaprezinc protects gastric mucosal cells from noxious agents through antioxidant properties in vitro: Aliment Pharmacol Ther. 1999;13:261-269
31. Yanase K, Funaguchi N, Iihara H, Yamada M, Kaito D, Endo J, Ito F, Ohno Y, Tanaka H, Itoh Y, Minatoguchi S. Prevention of radiation esophagitis by polaprezinc (zinc L-carnosine) in patients with non-small cell lung cancer who received chemo radiotherapy: International journal of clinical and experimental medicine. 2015;8(9):16215.
32. van der Hulst RR, Von Meyenfeldt MF, Deutz NEP, Soeters PB, Brummer RJM, von Kreel BK, Arends JW. Glutamine and the preservation of gut integrity: The Lancet. 1993;341(8857), 1363-1365.
33. De-Souza D, Greene L. Intestinal permeability and systemic infections in critically ill patients: effect of glutamine: Critical Care Medicine. 2005;33(5):1125-1135. doi:10.1097/01.ccm.0000162680.52397.97.
34. Hu Y, Xu J, Hu Q. Evaluation of antioxidant potential of aloe vera (aloe barbadensis miller) extracts: J Agric Food Chem. 2003;51(26):7788-7791. doi:10.1021/jf034255i.
35. Lee K, Weintraub S, Yu B. Isolation and identification of a phenolic antioxidant from Aloe barbadensis. Free Radical Biology and Medicine. 2000;28(2):261-265. doi:10.1016/s0891-5849(99)00235-x.
36. Vogler B, Ernst E. Aloe vera: a systematic review of its clinical effectiveness: British Journal of General Practice [Internet]. 1999 [cited 2015 Dec 16];49:823-828. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1313538/pdf/10885091.pdf.
37. Niklasson A, Lindstrom L, Simren M, Lindberg G, Bjornsson E. Dyspeptic symptom development after discontinuation of a proton pump inhibitor: A double – blind placebo controlled trial: Am J Gastroenterol.2010 Jul;105(7) 1531-7.
38. How to supplement with betaineHCl for low stomach acid [Internet]. SCDLifestyles.[cited 2016 Jan 30]. Available from: http://scdlifestyle.com/2012/03/how-to-supplement-with-betaine-hcl-for-low-stomach-acid/.

39. Peek RM. Helicobacter pylori and gastroesophageal reflux disease: Curr Treat Options Gastroenterol.2004;7:59–70.

40. Nasser SC, Slim M, Nassif JG, Nasser SM. Influence of proton pump inhibitors on gastritis diagnosis and pathologic gastric changes: World Journal of Gastroenterology: WJG. 2015 Apr 21;21(15):4599.

41. Lombardo L, Foti M, Ruggia O, Chiecchio A. Increased incidence of small intestinal bacterial overgrowth during proton pump inhibitor therapy: Clinical Gastroenterology and Hepatology. 2010 Jun 30;8(6):504-8.
42. Theisen J, Nehra D, Citron D, Johansson J, Hagen JA, Crookes PF, DeMeester SR, Bremner CG, DeMeester TR, Peters JH. Suppression of gastric acid secretion in patients with gastroesophageal reflux disease results in gastric bacterial overgrowth and deconjugation of bile acids: Journal of Gastrointestinal Surgery. 2000 Feb 1;4(1):50-4.
43. Ratuapli SK, Ellington TG, O’Neill MT, Umar SB, Harris LA, Foxx-Orenstein AE, Burdick GE, DiBaise JK, Lacy BE, Crowell MD. Proton pump inhibitor therapy use does not predispose to small intestinal bacterial overgrowth: The American Journal of Gastroenterology. 2012 May 1;107(5):730-5.
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What’s The Right SIBO Diet For You? With so many diet choices out there, it can feel so overwhelming… if you’re not sure where to start, this guide will help you discover exactly which one is right for you.


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