Do Antacids Treat Hemochromatosis ? Listen to the Patients — They Will Teach You Medicine

It was in the early 1980’s and I was perhaps 3 years out of my fellowship training at Stanford, when a patient taught me an invaluable rule: listen to the patients.

I was supervising our cardiac rehabilitation program at Brown, when one of my patients, a smart guy and a lawyer, told me that oats reduced cholesterol levels. We all know now that oats lower cholesterol, but we didn’t know that then. I summarily dismissed the idea, but he asked me to measure his cholesterol level. He would then follow a high oat cereal diet, and we would re-measure his cholesterol four weeks later. It was remarkable; he had about a 40 mg/dl drop in his LDL- cholesterol level, which was noteworthy in those days before statins, and at a time when cholesterol management consisted of low-saturated fats diets, niacin, cholestyramine, and clofibrate. Soon after this encounter, I noticed studies suggesting that the soluble fiber in oats reduces cholesterol levels. Soluble fiber is the white, foamy material you produce when you cook old-fashioned oatmeal. Insoluble fiber, cellulose, like wheat bran, is great for moving things along in the colon, but does little to nothing for cholesterol levels. The mechanisms by which oat fiber lowers cholesterol levels is not definitely defined. Bile is made from cholesterol and oat fiber appears to increase bile secretion and reduce its reabsorption. Alternatively, oat fiber may alter the gut microbiome and thereby reduce lipid levels by yet-to-be-defined mechanisms. (1) Other soluble fiber, like that in beans, also lowers cholesterol levels. The rumor is that one study showed similar soluble fiber effects from beans and oats, but that the research subjects eating the beans had 30% fewer friends. (Spoiler alert: That was a joke.)

My experience with the lawyer taught me to listen to patients. And the lessons keep coming. In early December 2023, I was on the coronary care unit rotation, and we had a patient with hemochromatosis who was admitted with an acute coronary syndrome. The intern mentioned that the patient had told her that he previously required frequent phlebotomies, but that after he developed a peptic ulcer and was treated with a proton pump inhibitor, he needed remarkably fewer phlebotomies, even after the ulcer was cured and any bleeding stopped. The intern did not know why, and neither did I, but one of the residents suggested that it was probably the antacid’s effect on iron (Fe) metabolism. The resident also provided an article that describes the mechanisms of Fe absorption.(2) In summary, the absorption of Fe in the duodenum and proximal jejunum depends on the Fe’s redox state. Fe exists at physiological pH in the ferric or Fe+3 form. Fe+3 must be converted to the ferrous or Fe+2 state to be absorbed. The low pH of gastric acid in the proximal duodenum allows a ferric reductase enzyme, duodenal cytochrome B, on the brush border of the enterocytes to convert the insoluble ferric (Fe+3) to the absorbable ferrous (Fe+2) ions. That is why it is often recommended to take Fe supplements with acidic orange juice. It is very possible that our patient’s proton pump inhibitor, reduced his stomach acid, and prevented Fe+3 being converted to Fe+2 thereby reducing Fe absorption.

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I cannot prove this. I did a Pubmed search using the search terms “antacid” and “hemochromatosis”, but got only two hits, one a hypothesis paper, (3) and neither paper referred to antacids specifically. Also, a Google search using “drugs that help hemochromatosis” produced no articles on antacids. Nevertheless, I learned a lot about Fe metabolism evaluating this idea, and I just wonder if our patient isn’t on to something.

It’s amazing what patients teach us if we listen.

1. Joyce SA, Kamil a, Fleige L, Gahan CGKM. The Cholesterol-Lowering Effect of Oats and Oat Beta Glucan: Modes of Action and Potential Role of Bile Acids and the Microbiome. Front Nutr. 2019 Nov 27;6:171,PMID: 31828074

2. Ems T, St. Lucia, K, Huecker MR. Biochemistry, Iron Absorption, In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan. PMID: 28846259

3. Robertson DS. The chemical reactions in the human stomach and the relationship to metabolic disorders. ed Hypotheses. 2005;64(6):1127–31. PMID: 15823700