30 years on a drug
studied for 8 weeks.

There is a moment in medicine — rarely acknowledged, rarely examined — when a short-term solution becomes a permanent fixture. Not because the original problem persists. Not because the evidence supports ongoing use. But because the prescription was never reviewed, the patient continued collecting repeats, and somewhere between the acute episode that warranted treatment and the present day, the drug became part of the furniture.

My father's omeprazole began, as most PPI prescriptions do, with a legitimate indication. Reflux. Acid-related symptoms significant enough to warrant a proton pump inhibitor. The evidence for short-term PPI therapy in this context is solid — these are effective medications for acute acid-related conditions. The studies that established this were typically 8 to 12 weeks in duration. That is the evidence base. That is what the clinical trials show.

He has been taking it for almost 30 years.

Nobody stopped to ask whether the original indication was still present. Nobody assessed whether the drug was still necessary or whether lifestyle changes had made it redundant. And nobody — in three decades of repeat prescriptions — ran the blood panel that would have shown what chronic acid suppression was doing to his iron, his magnesium, his B12, and his zinc. The four nutrients most consistently depleted by long-term PPI use. The four nutrients with direct implications for cardiac health, neurological function, and energy metabolism in a man who has had multiple heart attacks and is now dealing with advancing dementia.

This is not a story about a negligent GP. It is a story about a system that was not designed to ask the questions that matter over the long term — and about what happens when it doesn't.

How Drug-Nutrient Depletion Works

Medications affect nutrient status through mechanisms that are well-understood, predictable, and documented in the pharmacological literature. Some compete directly with nutrients for absorption. Some increase urinary excretion. Some deplete the cofactors the body needs to metabolise the drug itself. And some — like omeprazole — work by suppressing the very physiological process required to absorb multiple essential nutrients.

Gastric acid is not an inconvenience to be suppressed. It is a carefully regulated part of digestion. It denatures proteins to begin protein digestion. It activates pepsin. It creates the acidic environment required for the absorption of iron, calcium, magnesium, zinc, and vitamin B12. Suppress gastric acid production chronically and you impair the absorption of all five. Not dramatically, not all at once — but progressively, measurably, over months and years.

In a young, healthy person with good nutritional status, this depletion may take years to become clinically evident. In an older man with existing cardiovascular disease, reduced dietary variety, and a gut that has been managing reduced acid output for three decades — it becomes part of the clinical picture much faster, and compounds everything else that is already compromised.

The Most Clinically Significant Depletions

PPIs are far from alone in this. The pattern of prescribed medication quietly depleting the nutrients needed to manage the very condition being treated runs across the most commonly prescribed drug classes in the UK.

The Polypharmacy Problem

My father is not unusual in taking multiple medications simultaneously. This is the norm in older adults with chronic conditions — statins for cholesterol, antihypertensives for blood pressure, PPIs for acid, anticoagulants following cardiac events. Each medication was prescribed for a legitimate reason. Each one depletes something. And the depletions interact.

A man on a statin, a PPI, and a loop diuretic is simultaneously depleting CoQ10 (needed for cardiac muscle energy), magnesium (needed for cardiac rhythm and vascular tone), and iron and B12 (needed for oxygenation and neurological function). These are not separate problems. They are a converging depletion cascade affecting the systems the medications were prescribed to protect.

This is not an argument against the medications. Statins reduce cardiac events. Antihypertensives reduce stroke risk. PPIs manage genuine acid-related pathology. There is a time and a place for all of them, and the evidence for their use in appropriate clinical contexts is real. The argument is simpler than that: if you are going to prescribe something long-term, you should also monitor what it depletes long-term. This is not a radical position. It is basic clinical housekeeping that the system was not designed to provide.

What Should Have Been Done Differently

This is not hindsight. The evidence on PPI-induced magnesium depletion is old enough that the European Medicines Agency issued a formal warning about it in 2012. The evidence on metformin and B12 is in the NICE guidelines — monitoring is recommended for long-term users, though inconsistently applied. The evidence on statin-induced CoQ10 depletion has been in the literature for decades. The information exists. The system just wasn't built to act on it routinely.

In practice, the minimum that should accompany any long-term medication prescription — particularly in older adults — is a periodic review of the nutrient status most predictably affected by that medication. Not an extensive functional panel. Just the markers most directly relevant to what the drug is doing. RBC magnesium for anyone on long-term PPIs or diuretics. B12 for anyone on long-term metformin or PPIs. CoQ10 for anyone on long-term statins. These are not exotic tests. They are straightforward, inexpensive, and clinically meaningful.

For my father, three decades in, the picture is more complex. The depletions are established, the interactions are layered, and the priority is to understand what is actually there before making any supplementation decisions — because iron, for example, should not be supplemented without understanding the inflammatory picture, the ferritin level, the gut absorption capacity, and the cardiac context simultaneously. This is why a comprehensive panel matters more than a targeted one at this stage.

When Medications Interact With Each Other’s Depletions

My father’s situation involves multiple medications simultaneously. This is the norm in older adults with chronic conditions. And the depletions are not simply additive — they interact. Each drug depletes something that another drug needs, or that the body needs to handle the other drugs, or that was already being depleted by a third drug in the stack.

A statin depletes CoQ10, impairing mitochondrial energy production in cardiac muscle. A PPI taken alongside it depletes magnesium, iron, and B12 — magnesium being essential for cardiac rhythm and vascular tone, iron for oxygenation, B12 for the homocysteine metabolism that affects vascular health. A loop diuretic added to the stack increases urinary excretion of magnesium and potassium — two electrolytes already under pressure from the PPI. The result is a converging depletion cascade affecting the very systems the medications were prescribed to protect. No single prescriber sees the full picture. Each decision is individually defensible. The combined nutrient impact is nobody’s specific responsibility to monitor.

The Phosphoric Acid Problem Nobody Discusses

Cola drinks contain phosphoric acid — specifically to provide the characteristic sharp taste. Unlike organic phosphates found in food, phosphoric acid is inorganic and rapidly absorbed. When consumed in large amounts daily, it produces a specific and underappreciated depletion cascade.

The body detects a spike in serum phosphate and responds by releasing parathyroid hormone to excrete the excess through the kidneys. Do this repeatedly — several cans a day over months and years — and the kidneys are in continuous phosphate excretion. Total body phosphate stores deplete even though serum levels may appear normal between drinks until the depletion becomes severe. The result is hypophosphatemia, which causes profound muscle weakness including the diaphragm and intercostal muscles. The presenting complaint is breathlessness and chest wall pain — frequently attributed to cardiac or respiratory pathology until the blood test reveals the phosphate.

Phosphoric acid also binds calcium and iron in the gut, forming insoluble compounds that cannot be absorbed. In someone with existing iron deficiency anaemia on an acid-suppressing medication that already impairs iron absorption, adding regular cola intake creates a triple block: insufficient acid, phosphate binding in the gut, and competing inhibitors from other beverages. High sugar intake drives urinary magnesium excretion and creates the blood glucose instability that destabilises neuronal firing. When phosphate depletion impairs ATP production and blood sugar swings create neuronal instability in the brain and inner ear — among the most energy-hungry tissues in the body — the result is the triad of headache, vertigo, and fatigue that follows patients through years of specialist appointments without resolution.

The hospital treats the blood test result. The dietary driver continues. Three days of phosphate supplementation resolves the acute depletion. The cola continues. The phosphate drops again.

Medication Overuse Headache — The Treatment Causing the Symptom

When simple analgesics — paracetamol, ibuprofen, triptans — are taken more than 10 to 15 days per month for headache, they trigger a rebound phenomenon. The headache returns as the drug clears, driving the patient to take the next dose. The medication taken to relieve the headache becomes the cause of the next one.

This is estimated to affect 1–2% of the general population and a much higher proportion of people attending headache clinics. It is rarely identified because patients do not associate their painkiller with causing headaches — the thought seems counterintuitive — and clinicians rarely ask how frequently analgesics are being taken in a chronic headache presentation. The treatment is tapering withdrawal, which produces temporary worsening before improvement. Without identifying the cycle, the headaches are attributed to everything except the drug perpetuating them.

Are Your Symptoms the Medication?

This is the question almost nobody is asked at the point of symptom presentation. Fatigue in a statin user. Tingling in a metformin user. Palpitations in someone on a PPI. Low mood in a long-term oral contraceptive user. These presentations are common. They are also exactly what you would predict from the known depletion profiles of those medications. Yet they are routinely attributed to something else — age, stress, lifestyle, a new condition requiring a new medication — rather than traced back to the drug that may be causing them.

It does not make the medication wrong. It makes the incomplete clinical picture wrong. And fixing an incomplete picture starts with asking the right questions — including the one nobody asked about the omeprazole that has been in my father's prescription for 30 years.