by Kenneth R. DeVault, MD, FACG
President, American College of Gastroenterology
I want to make you aware of two articles published in the Red Section of The American Journal of Gastroenterology addressing some of the concerns related to the ongoing controversy surrounding the long-term safety of proton pump inhibitors.
In addition, a recent mechanistic study has suggested an endovascular effect of PPI that might, if confirmed in additional studies, potentially explain some of the cardiovascular, renal and neurological associations.
The AJG editors invited the European perspective on overuse of PPI. Read Dr. Angel Lanas’ Red Section article HERE. Dr. Lanas relates the major improvement in health that can be achieved with the proper use of these agents, but then outlines areas where they may tend to be used inappropriately. In Europe, the most common inappropriate use of PPI is for the prevention of gastric damage in co-therapy with agents which have a low or at times no risk of significant gastric damage and in the prevention of stress-induced bleeding. PPI are often started as an inpatient and continued on discharge for non-indicated reasons. The risks of PPI are probably relatively low, but that benefit-to-risk ratio becomes very low when there is almost not demonstrable benefit. He calls on our profession to attempt to self-regulate inappropriate PPI use.
Also in the Red Section, Dr. Loren Laine gives his perspective on PPI use. Read Dr. Laine’s article HERE. He admits that these as-yet unproven risks are indeed important and need to be watched. He goes on to emphasize the conditions where PPI therapy may or may not be beneficial. The first is reflux disease where PPI are effective and commonly used, but can be replaced by less aggressive agents in many cases. Even in patients with erosive esophagitis and Barrett’s esophagus, the true benefit of long-term PPI therapy is not clear. It is clear that ulcer prevention is actually needed in a subset of NSAID users and that long-term PPI are most assuredly indicated, but these agents are not needed in low-risk patients. His conclusions are summarized in the table below.
Two blogs in a row on this subject resulted not just from the press and publications related to the topic, but from the many questions raised by my patients. I continue to refine my thoughts on this subject and am trying to let the following principles provide guidance.
- Face up to the possibility that some of the associations may be true.
- Know why the patient is on the medication. They may not really need it.
- For reflux patients, emphasize life-style changes, particularly diet and weight loss.
- Practice step-down therapy seeking the lowest form of acid suppression that provides adequate symptom relief.
- Make sure patients understand that fear of these rare complications is not a reason to choose reflux surgery.
Ken
Double-click to view table.