Proton Pump Inhibitors and Endurance Athletes

A proton pump inhibitor (PPI) is a medication used to treat the symptoms of acid reflux, nausea and heartburn as a result of many different conditions. (NB: If you have these symptoms and need advice, please see your GP as this post is not intended as a diagnostic or prescriptive tool.) PPIs work by blocking the little pumps in your stomach that produce acid, they take about 3 days to reach full effect and 48hrs for those effects to stop once you cease the medication.

An athlete I know has recently been started on PPIs as a regular medication and though it’s helping with their symptoms, they aren’t sure if long term use might affect their ability to train and recover. On the flip side, I was recently listening to a Q&A triathlon podcast where someone had written in saying they experienced reflux in their last race and the (non-medical) host suggested taking a PPI on race morning to help with the symptoms (hint: not a great idea!)  I thought I’d put together a little resource for anyone who might be considering taking PPIs, whether as a regular medication or a race day help.

The first distinction to make is the reason someone might take PPIs. Some athletes may have ongoing symptoms of reflux/nausea/heartburn even when they are not exercising, and have had a doctor prescribe them the medication. This is usually an 8-week trial to see if symptoms resolve. Sometimes a gastroscopy (camera down into your stomach) is also performed to help with the diagnosis. In this case, PPIs can help the athlete get back to training without feeling unwell and enables them to return to eating relatively normally in order to support their physical needs. The questions begin to arise when they feel good using the PPI, but are scared of taking it long term (i.e for years) because A) we are athletes who are fit and well so why should we need to be taking pills every day? and B) Doesn’t long term medication use always have some side effects?

The second group of athletes I want to talk about are those who are normally symptom free, but experience heartburn or reflux when they begin exercising, or during a race. These athletes may consider whether taking over the counter (where you don’t need a prescription) PPIs in the lead up to an important race could help them prevent race-day stomach problems. But are there any issues with doing this?

Group 1: Athletes on long term PPIs

If you google “proton pump inhibitor side effects” you will find a massive list of everything that they can potentially cause including nausea (ironic), pneumonia, intestinal infections, dementia, osteoporosis/fractures and fatigue. The important thing to remember here is that these are dependent on the dose, duration of therapy, and the physical level of the patient. PPIs are used in very old, very frail and very sick individuals, so as an athlete your risk profile is not likely to be as dire as someone receiving this medication in the Intensive Care Unit.

All this considered, the main concerns for athletes using PPIs long term relate to nutrition and vitamin absorption. This is partly because they have a higher requirement for these things than the general population, and that any deficiencies can negatively impact performance and recovery.

Iron is important for the capacity of our bodies to deliver oxygen from our lungs to the working muscles. Low iron (low ferritin on a blood test) can cause feelings of extreme fatigue, weakness and emotional stress even if athletes are not technically “anaemic”. The iron available in food we eat needs to be activated by stomach acid before it can be absorbed. You might have also heard that vitamin C helps with iron absorption, so it is very handy that the body secretes this into the stomach with the acid. When someone is taking PPIs, it lowers the volume of acid and vitamin C secreted, and may reduce the absorption of iron. I could only find a couple of studies looking at the association between PPIs and anaemia, which both found that PPI use caused a reduction in red blood cells and haemoglobin (Hb) levels. However, the first study didn’t actually measure blood iron (ferritin) levels and some of the patients had other illnesses (such as cancer) that also reduce Hb levels, and the second study was on patients with advanced heart disease – not the healthy athlete population we are interested in!
Conclusion: If you are someone taking PPIs long term, it might pay to have your ferritin levels checked before beginning PPI therapy and then at regular intervals (6-12 months as recommended by your GP or sports doc 😉 ) This is especially important for female athletes who are menstruating regularly (losing iron) or are low meat athletes (less haeme iron absorption), as they are prone to lower ferritin levels.

A similar story to iron, calcium needs to be broken down by stomach acid in order to be absorbed, so theoretically the use of PPIs might impair calcium uptake. The good news is that this doesn’t seem to be the case in short term studies here and here. There are several studies showing an association between PPI use and fractures, however the Therapeutic Goos Administration (TGA) reports that most of them are “observational studies” and therefore not as reliable. To date, there are also some studies which demonstrate bone strengthening effects of PPIs.
Conclusion: The jury is out as to whether you are a higher risk for fractures and osteoporosis using PPIs, so the difference is probably negligible in our fit athletes not on any other medications. This means that for athletes who have a good calcium intake (eat more cheese!) there should be no need to take calcium supplements purely because you’re on a PPI.

There have been a handful of reported cases of severe low levels of magnesium with long term (average 5.5yrs, up to 13yrs) therapy, some requiring hospitalisation and not improving with magnesium supplements. There were no particular characteristics that helped identify which patients were at risk, and researchers were unable to determine what had caused it.  The TGA released an update regarding low magnesium and PPIs back in 2011, but it is difficult for doctors to test everyone taking them, especially those who buy them over the counter.
Conclusion: If you are taking them long term it might be worth asking your GP whether they would consider testing your magnesium levels. Magnesium is vital for athletic performance and low levels due to PPIs cannot be corrected with supplements or eating foods high in Mg. If the levels are low, they might require ongoing monitoring or switching to a different medication- chat to your doc!

The major concern regarding B12 (which is usually found in animal foods- meat, milk, egg, fish, and shellfish) is that a deficiency can lead to nervous system problems and cognitive decline- including dementia. Again, B12 absorption into the body requires gastric acid to break it away from proteins so it can enter the bloodstream. Low acid from PPIs means this doesn’t happen as effectively. A large trial published just last year showed that the risk of dementia was significantly increased in patients over 75 who were taking PPIs. This supports an earlier trial done in mice where they found higher levels of beta-amyloid protein (“dementia” protein) in the brains of mice on PPIs. Despite these findings, it’s still hard to say that PPIs cause dementia, but they might be a risk factor in someone who is already susceptible.
Conclusion: If you have concerns, speak to your doctor about your risk and possibly get tested if you can. Taking supplements or eating more meat might not help if the issue is that you are unable to absorb it. B12 deficiency is relatively easy to treat, so if you are worried about it don’t be afraid to speak up.


Group 2: Athletes who suffer from reflux/heartburn when exercising.

Reflux symptoms are very common among endurance athletes and can be a disruptive and uncomfortable experience in training and racing. In runners, it has been shown that the muscles in the lower oesophagus (which joins the mouth and stomach) relax during running, causing acid to flow back the wrong way, which gives you that burning feeling. Also implicated are the changes in blood flow away from the stomach and to the working muscles, hormonal changes during exercise and increased pressure in the abdomen. Symptoms tend to be worse after eating, and vary with the duration and intensity of exercise.


Strategies to reduce reflux while exercising without taking medication

  • Avoid eating solid food within 3 hours of racing
  • Always stay away from NSAIDs (ibuprofen, neurofen, advil) because they can damage your stomach lining
  • Try to minimise caffeine in the day or two before the race (not easy, I know)
  • Adequate hydration during the race
  • As always- nothing new on race day
  • During the race, eat food in small amounts, rather than smashing a whole cliff bar at once on the bike
  • Don’t eat foods that require a lot of digestion on race morning- bacon!


Will it help to take a PPI on race morning?
PPIs take 3 days to reach their full effect, so just popping one on race morning will not be helpful at all. Aside from the “nothing new on race day” rule, taking a new medication for a race is just not a good idea! So what if you start a few days earlier? One study looked at healthy athletes who did two treadmill runs, taking a placebo pill for 6 days for one of them, and then a small dose of PPI for 6 days before the other. Athletes didn’t know which one they were taking at the time.  Researchers measured the athletes acid levels in the oesophagus and symptoms both with and without medication. They found that the acid levels were lower when they took the PPIs, but that it didn’t help with the symptoms at all.

Conclusion: There are lots of small things you can do to help prevent reflux in a race, so medication should not be the first port of call. If you think you might benefit from PPIs, it is worth consulting a GP or sports medicine physician for an opinion. The most important thing is getting checked out if you are having these symptoms in order to rule out anything sinister.






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