Proton pump inhibitors and risk of 1-year mortality and rehospitalization in older patients discharged from acute care hospitals

Association between Proton Pump Inhibitor Use and Risk of Incident Chronic Kidney Disease: Systematic Review and Meta-Analysis

INTRODUCTION

Proton pump inhibitors (PPIs) are among the most commonly prescribed medications. Recently, PPI use has been linked to the development of chronic kidney disease (CKD) and cardiovascular events. Our study aimed to investigate the relationship between PPI use and the incidence of chronic kidney disease using a systematic review and meta-analysis.

METHODS

We performed a comprehensive literature search in PubMed, Embase, and Cochrane databases from their inception until March 2024 for relevant studies. We compared outcomes between patients using PPIs, those not using PPIs, and those using histamine-2 receptor antagonists (H2RAs). Endpoints were pooled using the DerSimonian-and-Laird random-effects model as the hazard ratio (HR) with 95% confidence intervals (CIs).

RESULTS

Our analysis included twelve studies with a total of 700,125 participants (286,488 on PPIs, 373,848 not on PPIs, and 39,789 on H2RAs), with follow-up periods ranging from three months to 14 years. The current meta-analysis revealed that PPI use is associated with a statistically significant increased risk of incident CKD (HR: 1.26, 95% CI: 1.16-1.38, p < 0.001) compared with non-users. Moreover, the risk of incident CKD is significantly higher in patients with PPI use compared to H2RA use (HR: 1.34, 95% CI: 1.13-1.59, p < 0.001). The results remained unchanged in terms of magnitude and direction after a leave-one-out analysis for both outcomes.

CONCLUSIONS

Our multifaceted analysis showed that PPI use was associated with a higher incidence of CKD when compared to non-PPI use and H2RA use, respectively. These findings advocate for heightened vigilance and judicious use of long-term PPIs. Further large prospective longitudinal studies are warranted to validate these observations.

Gastric Acid Suppression Therapy and Its Association with Peritoneal Dialysis-Associated Peritonitis in the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS)

Key Points

In a large multinational cohort of PD patients, any GAS use was not associated with an increased risk of all-organism peritonitis. For peritonitis, risks were particularly high among certain classes of organisms particularly for Gram-negative, enteric, and streptococcal peritonitis episodes. The association with enteric peritonitis appeared to be stronger among H2RA users.

Background

Peritonitis is a major peritoneal dialysis–related complication. We determined whether gastric acid suppression (GAS) (proton pump inhibitor [PPI] or histamine-2 receptor antagonists [H2RAs]) use was associated with all-cause and organism-specific peritonitis in peritoneal dialysis patients.

Methods

In the Peritoneal Dialysis Outcomes and Practice Patterns Study (595 facilities, eight countries, years 2014–2022), associations between GAS use and time to first episode of all-cause peritonitis were examined using Cox proportional hazards models. The primary exposure of interest was GAS and secondarily PPI or H2RA use. Secondary outcomes were organism-specific peritonitis, peritonitis cure rates, and death.

Results

Among patients (N =23,797) at study baseline, 6020 (25.3%) used PPIs, and 1382 (5.8%) used H2RAs. Overall risks of GAS use and peritonitis risk (adjusted hazard ratio [AHR]=1.05, 95% confidence interval [CI], 0.98 to 1.13]) and use of PPI (AHR 1.06 [95% CI, 0.99 to 1.14]) or H2RA (AHR 1.02 [95% CI, 0.88 to 1.18]) did not reach statistical significance. In organism-specific analyses, GAS users displayed higher peritonitis risks for Gram-negative (AHR 1.29, 95% CI, 1.05 to 1.57), Gram-positive (AHR 1.15, 95% CI, 1.01 to 1.31), culture-negative (AHR 1.20, 95% CI, 1.01 to 1.42), enteric (AHR 1.23, 95% CI, 1.03 to 1.48), and particularly Streptococcal (AHR 1.47, 95% CI, 1.15 to 1.89) peritonitis episodes. GAS was also associated with higher overall mortality (AHR 1.13 [95% CI, 1.05 to 1.22]).

Conclusion

The association between GAS use and peritonitis risk was weaker (hazard ratio [HR] 1.05 [0.98 to 1.13]) than for streptococcal (HR 1.57 [1.15 to 1.89]) and Gram-negative (HR 1.29 [1.05 to 1.57]) peritonitis. A better understanding of mechanisms surrounding the differential effects of GAS subtype on peritonitis risks is needed. Clinicians should be cautious when prescribing GAS. The impact of GAS deprescribing on peritonitis risk requires further evaluation.

Proton pump inhibitors associated with an increased risk of mortality in elderly: a systematic review and meta-analysis

PURPOSE

The increased use of proton pump inhibitors (PPIs) in the elderly has raised concerns about potential severe adverse effects. Our systematic review investigated the mortality associated with PPI use in elderly populations.

METHODS

We searched MEDLINE, EMBASE, and the Cochrane Library for relevant publications until August 2022. We included randomized controlled trials (RCTs), quasi-RCTs, and observational studies on the association between proton pump inhibitors and mortality in the elderly. To estimate the pooled relative risk (RR) and 95% confidence interval (CI), the inverse-variance random effect model was used. Heterogeneity was assessed using the I2 test. Subgroup analyses were performed by follow-up period, population, and study design.

RESULTS

A total of 4 RCTs and 36 cohort studies were included in the meta-analysis. Four RCTs showed that there was no significant association between PPIs and the risk of death. From 23 observational studies (26 cohorts), the use of proton pump inhibitors was not significantly associated with increased mortality in the elderly (RR 1.14; 95% CI, 0.90-1.45). However, when controlling for covariates from 33 observational studies (41 cohorts), proton pump inhibitors in older adults aged 50 years or more were significantly associated with a 15% higher risk of mortality compared to nonusers (RR 1.15; 95% CI, 1.10-1.20).

CONCLUSIONS

Our meta-analysis of RCTs found that PPIs did not show a significant association with increased mortality risk in older adults. However, the meta-analysis of cohort studies and long-term follow-up studies showed a higher increased risk of death with PPI use in older adults. The prescription of PPIs in patients aged 50 years or older should be carefully considered.

Timely Cessation of Proton Pump Inhibitors in Critically Ill Patients Impacts Morbidity and Mortality: A Propensity Score-Matched Cohort Study

OBJECTIVE

Proton pump inhibitors (PPIs) are among the drugs most commonly used in critically ill patients. Although mainly applied temporarily for stress ulcer prophylaxis, their application is frequently not terminated. Potential adverse effects of PPI treatment could impact the outcome in case of unnecessary and, therefore, avoidable long-term continuation. We tested the hypotheses that nonindicated PPI therapy continued beyond hospital discharge is associated with increased morbidity, rehospitalization rate, and mortality.

DESIGN

Nationwide retrospective cohort study considering critically ill patients treated on German ICUs between January, 2017, and December, 2018 with a 2-year follow-up.

SETTING

A total of 591,207 patient datasets of a German healthcare insurer were screened.

PATIENTS

We identified 11,576 ICU patients who received PPI therapy for the first time during their index ICU stay without having an indication for its continuation.

INTERVENTIONS

The cohort was stratified into two groups: 1) patients without further PPI therapy and 2) patients with continuation of PPI therapy beyond 8 weeks after hospital discharge.

MEASUREMENTS AND MAIN RESULTS

Frequency of predescribed adverse events associated with PPI therapy, 1-year rehospitalization rate, and 2-year mortality were determined. The proportion of patients with continued PPI therapy without an objectifiable indication was 41.7% (4,825 of 11,576 patients). These patients had a 27% greater risk of pneumonia (odds ratio [OR] 1.27; 95% CI, 1.15-1.39; p < 0.001) and a 17% greater risk of cardiovascular events (OR 1.17; 95% CI, 1.08-1.26; p < 0.001). Continued PPI therapy was associated with a 34% greater risk of rehospitalization (OR 1.34; 95% CI, 1.23-1.47) and a nearly 20% greater 2-year mortality risk (hazard ratio 1.17; 95% CI, 1.08-1.27; p = 0.006).

CONCLUSIONS

These data demonstrate that an unnecessary continuation of PPI therapy after hospital discharge may significantly impact morbidity and mortality. To avoid potentially harmful overuse of a PPIs, intensivists should ensure timely cessation of a temporarily indicated PPI therapy.

Polypharmacy, potentially inappropriate medications and associated factors among older adults with hypertension in primary care

OBJECTIVE

to identify the prevalence and associations of polypharmacy and potentially inappropriate medication use among older adults with hypertension treated in primary care.

METHODS

a cross-sectional study carried out with older adults with hypertension treated at a Family Health Strategy unit. Data collection included analysis of medical records, interviews and multidimensional assessment of older adults. Socio-demographic information and clinical variables were collected. Statistical analysis was performed by multiple logistic regression.

RESULTS

polypharmacy prevalence was 38.09%, and potentially inappropriate medication (PIM), 28.57%. There was a significant association between polypharmacy and PIM use, altered sleep and ethnicity. PIM use was associated with polypharmacy, worse family functioning, and absence of a caregiver. Cognitive decline reduces the prevalence of these medications.

CONCLUSIONS

polypharmacy and PIM use among older adults with hypertension represent a problem in this population, especially among the most vulnerable.

Potentially inappropriate medication use is associated with increased risk of incident disability in healthy older adults

BACKGROUND

Efforts to minimize medication risks among older adults include avoidance of potentially inappropriate medications (PIMs). However, most PIMs research has focused on older people in aged or inpatient care, creating an evidence gap for community-dwelling older adults. To address this gap, we investigated the impact of PIMs use in the ASPirin in Reducing Events in the Elderly (ASPREE) clinical trial cohort.

METHODS

Analysis included 19,114 community-dwelling ASPREE participants aged 70+ years (65+ if US minorities) without major cardiovascular disease, cognitive impairment, or significant physical disability. PIMs were defined according to a modified 2019 AGS Beers Criteria. Cox proportional-hazards regression models were used to estimate the association between baseline PIMs exposure and disability-free survival, death, incident dementia, disability, and hospitalization, with adjustment for sex, age, country, years of education, frailty, average gait speed, and comorbidities.

RESULTS

At baseline, 7396 (39% of the total) participants were prescribed at least one PIM. Compared with those unexposed, participants on a PIM at baseline were at an increased risk of persistent physical disability (adjusted hazard ratio [HR] 1.47, 95% confidence interval [CI] 1.21, 1.80) and hospitalization (adjusted HR 1.26, 95% CI 1.20, 1.32), but had similar rates of disability-free survival (adjusted HR 1.02; 95% CI 0.93, 1.13) and death (adjusted HR 0.92, 95% CI 0.81, 1.05). These effects did not vary by polypharmacy status in interaction analyses. PIMs exposure was associated with higher risk of disability followed by hospitalization (adjusted HR 1.92, 95% CI 1.25, 2.96) as well as vice versa (adjusted HR 1.54, 95% CI 1.15, 2.05). PPIs, anti-psychotics and benzodiazepines, were associated with increased risk of disability.

CONCLUSIONS

PIMs exposure is associated with subsequent increased risk of both incident disability and hospitalization. Increased risk of disability prior to hospitalization suggests that PIMs use may start the disability cascade in healthy older adults. Our findings emphasize the importance of caution when prescribing PIMs to older adults in otherwise good health.

Maintenance Proton Pump Inhibitor Use Associated with Increased All-Cause and Cause-Specific Mortality in Sweden

BACKGROUND

Proton pump inhibitor (PPI) use has increased over the last decades and has been associated with multiple adverse events and potentially even overall survival.

AIMS

We aimed to investigate the association between proton pump inhibitor maintenance use and all-cause and cause-specific mortality, addressing confounding by indication and duration of use.

METHODS

This Swedish population-based cohort study included all adult (N = 935,236) PPI and histamine-2 receptor antagonist maintenance users (≥ 180 days use) during 2005-2014. Standardised mortality ratios (SMRs) and 95% confidence intervals were calculated for all-cause and cause-specific mortality comparing the risk among PPI/H2RA users to that of the Swedish background population, stratified by age, sex, calendar period, indication and duration of use. Multivariable Poisson regression models were used to compare PPI use to H2RA use, expressed as incidence rate ratios and 95% confidence intervals.

RESULTS

PPI and histamine-2 receptor antagonist use were associated with an increased risk of all-cause mortality (SMR = 1.35; 1.34-1.36; SMR = 1.31; 1.27-1.36, respectively). The highest SMRs were found in the youngest age groups. In direct comparison, PPI use showed a higher mortality risk than histamine-2 receptor antagonist use (incidence rate ratios = 1.42; 1.38-1.46). PPIs were related to increased cancer (SMR = 1.21; 1.20-1.22), and cardiovascular mortality (SMR = 1.36; 1.35-1.37). Increased SMRs were observed for most indications. Longer duration of use was associated with a higher mortality among PPI users but not among histamine-2 receptor antagonist users.

CONCLUSION

Maintenance PPI use was associated with an increased risk of all-cause and cause-specific mortality, and the risk increased with prolonged duration.

Thürmann P. Potentially Inadequate Medications in the Elderly: PRISCUS 2.0

BACKGROUND

The term potentially inadequate medication (PIM) is used to describe substances that may be unsuitable for use inthe elderly and should be avoided. The PRISCUS list, published in 2010, was the first catalog of PIM designed for the Germandrug market to become adopted in practice. While 24% of German patients aged ≥ 65 years were prescribed at least one PIMper year in 2009, the proportion in 2019 was only 14.5%.

METHODS

In a three-round Delphi process, experts from clinical practice and research evaluated whether selected substancesare PIM for the elderly. The participants were provided with dedicated literature including systematic reviews carried out for theparticular purposes of this project.

RESULTS

Fifty-nine persons took part in the Delphi process and, in addition, contributed comments and therapeutic alternatives.Altogether, 187 substances were classed as PIM. One hundred thirty-three of the substances now listed were not in the originalPRISCUS list: these include some oral antidiabetics, all of the selective COX-2 inhibitors, and moderately long acting benzodiazepinessuch as oxazepam. For some other substances, e.g., proton pump inhibitors (PPI), the advisability of treatment formore than 8 weeks was considered as potentially inappropriate, as was the use of ibuprofen in doses >1200 mg/day and formore than 1 week without PPI. Risperidone for more than 6 weeks is also PIM.

CONCLUSION

The new, greatly extended PRISCUS list must now be validated in epidemiological and prospective studies and itspracticability in routine daily use must be verified.

Proton Pump Inhibitor Use and Risks of Cardiovascular Disease and Mortality in Patients with Type 2 Diabetes

BACKGROUND

Proton pump inhibitors (PPIs) are widely used drugs for gastric-acid-related diseases, which may have an impact on the gut microbiome. We aimed to evaluate the associations of PPI use with risks of cardiovascular disease (CVD) and all-cause mortality in patients with type 2 diabetes (T2D).

METHODS

We analysed the associations of PPI use with risks of coronary artery disease (CAD), myocardial infarction (MI), heart failure (HF), stroke, and all-cause mortality in 19,229 adults with T2D using data from the UK Biobank study.

RESULTS

During a median follow-up of 10.9-11.2 years, we documented a total of 2,971 CAD, 1,827 MI, 1,192 HF, and 738 stroke cases, along with 2,297 total deaths. PPI use was significantly associated with higher risks of CAD (HR, 1.27; 95% CI, 1.15-1.40), MI (HR, 1.34; 95% CI, 1.18-1.52), HF (HR, 1.35; 95% CI, 1.16-1.57) and all-cause mortality (HR, 1.30; 95% CI, 1.16-1.45). No significant association was observed between PPI use and stroke (HR, 1.11; 95% CI, 0.90-1.36). The results were consistent in the subgroup analyses stratified by factors including indications of PPI, anti-diabetic medication use, and antiplatelet drug use. Analyses in a 1:1 propensity score-matched cohort of PPI users versus non-users yielded similar results.

INTERPRETATION

Our data suggested that PPI use was associated with higher risks of CVD events and mortality among patients with T2D. The benefits and risks of PPI use should be carefully balanced among patients with T2D, and monitoring of adverse CVD events during PPI therapy should be enhanced.

Proton Pump Inhibitors and Hypomagnesemia in Older Inpatients: An Observational Study

Purpose Proton pump inhibitors (PPIs) are prescribed frequently and can cause potentially severe hypomagnesemia. Researchers assessed the prevalence of hypomagnesemia and the association between PPI use and hypomagnesemia in hospitalized older patients. Methods Researchers conducted a single-center, observational, retrospective cohort study with patients admitted to a geriatric ward at the Jeroen Bosch Hospital in the period between June 24, 2016, and August 30, 2020. Patients were included if they were 65 years of age or older, had a serum magnesium measurement, and a complete overview of patient’s current medication was present at the day of admission. The primary outcome was the occurrence of hypomagnesemia at hospital admission. Exposure to PPIs was the primary determinant investigated. Covariates were studied to identify risk factors and to adjust for potential confounding. The strength of the association between PPI and hypomagnesemia was evaluated with unconditional logistic regression, expressed as odds ratios (ORs) with 95% confidence intervals (CIs). Results The prevalence of hypomagnesemia was 21.9% in PPI users and 15.8% in non-PPI users. Overall, the use of PPIs was associated with hypomagnesemia (ORadj = 1.38, 95% CI 1.09-1.76). A trend for this association was most pronounced in male patients (ORadj = 1.88, 95% CI 1.27-2.79), smokers (ORadj = 3.95, 95% CI 1.52-10.28), and in patients using > 7 units alcohol a week (ORadj = 4.44, 95% CI 1.40-14.12). Conclusion Older patients who are taking a PPI have a higher risk of developing hypomagnesemia than nonusers; additional factors can contribute to the risk. Physicians should be aware of PPI-induced hypomagnesemia and routinely monitor serum magnesium levels in older patients.

Association of Proton Pump Inhibitor Use With All-Cause and Cause-Specific Mortality

BACKGROUND & AIMS

The use of proton pump inhibitors (PPIs) has increased rapidly in the past 2 decades. Concerns about the regular use of PPIs contributing to mortality have been raised.

METHODS

We conducted a prospective cohort study using data collected from the Nurses' Health Study (2004-2018) and the Health Professionals Follow-up Study (2004-2018). Cox proportional hazards models were used to estimate the hazard ratios (HRs) and 95% CIs for mortality according to PPI use. We used a modified lag-time approach to minimize reverse causation (ie, protopathic bias).

RESULTS

Among 50,156 women and 21,731 men followed for 831,407 person-years and a median of 13.8 years, we documented 22,125 deaths, including 4592 deaths from cancer, 5404 from cardiovascular diseases, and 12,129 deaths from other causes. Compared with nonusers of PPIs, PPI users had significantly higher risks of all-cause mortality (HR, 1.19; 95% CI, 1.13-1.24) and mortality due to cancer (HR, 1.30; 95% CI, 1.17-1.44), cardiovascular diseases (HR, 1.13; 95% CI, 1.02-1.26), respiratory diseases (HR, 1.32; 95% CI, 1.12-1.56), and digestive diseases (HR, 1.50; 95% CI, 1.10-2.05). Upon applying lag times of up to 6 years, the associations were attenuated and no longer statistically significant (all-cause: HR, 1.04; 95% CI, 0.97-1.11; cancer: HR, 1.07; 95% CI, 0.89-1.28; cardiovascular diseases: HR, 0.94; 95% CI, 0.81-1.10; respiratory diseases: HR, 1.20; 95% CI, 0.95-1.50; digestive diseases: HR, 1.38; 95% CI, 0.88-2.18). Longer duration of PPI use did not confer higher risks for all-cause and cause-specific mortality.

CONCLUSIONS

After accounting for protopathic bias, PPI use was not associated with higher risks of all-cause mortality and mortality due to major causes.

Proton Pump Inhibitor Therapy for Eosinophilic Esophagitis: History, Mechanisms, Efficacy, and Future Directions

Over the past decade, the role of proton pump inhibitor (PPI) medication has evolved from a diagnostic tool for Eosinophilic Esophagitis (EoE), by excluding patients with PPI responsive esophageal eosinophilia (PPI-REE), to a therapy for EoE. This transition resulted from the Updated International Consensus Diagnostic Criteria for Eosinophilic Esophagitis: Proceedings of the Appraisal of Guidelines for Research and Evaluation II (AGREE) Conference to support PPI therapy for EoE in children and adults. Additional recent advances have suggested a role for genetic variations that might impact response to PPI therapy for EoE. This review article will explore a brief background of EoE, the evolution of PPI therapy for EoE and its proposed mechanisms, efficacy and safety in children and adults, and considerations for future PPI precision medicine in patients with EoE.

No Associations Between Regular Use of Proton Pump Inhibitors and Risk of All-Cause and Cause-Specific Mortality: A Population-Based Cohort of 0.44 Million Participants

INTRODUCTION

The association between proton pump inhibitors' (PPIs) use and mortality remains unclear.

METHODS

This was a prospective analysis of 440,840 UK residents and 13,154 deaths. We evaluated the associations with multivariate Cox regression.

RESULTS

After adjusting for confounders, such as over health status and longstanding diseases, the regular use of PPIs was not associated with an increased risk of all-cause mortality and mortality due to neoplasms, circulatory system diseases, respiratory system diseases, digestive system diseases, external causes, and other causes.

DISCUSSION

Regular use of PPIs was not associated with an increased risk of all-cause and cause-specific mortality.

Antithrombotic therapy in the elderly and senile age: the consensus opinion of experts of the Russian Association of Gerontologists and Geriatricians and the National Society of Preventive Cardiology

В данном документе обсуждаются особенности АТТ у лиц пожилого и старческого возраста в различных клинических ситуациях.

Surgical treatment of GERD: systematic review and meta-analysis

BACKGROUND

Gastroesophageal reflux disease (GERD) has a high worldwide prevalence in adults and children. There is uncertainty regarding medical versus surgical therapy and different surgical techniques. This review assessed outcomes of antireflux surgery versus medical management of GERD in adults and children, robotic versus laparoscopic fundoplication, complete versus partial fundoplication, and minimal versus maximal dissection in pediatric patients.

METHODS

PubMed, Embase, and Cochrane databases were searched (2004-2019) to identify randomized control and non-randomized comparative studies. Two independent reviewers screened for eligibility. Random effects meta-analysis was performed on comparative data. Study quality was assessed using the Cochrane Risk of Bias and Newcastle Ottawa Scale.

RESULTS

From 1473 records, 105 studies were included. Most had high or uncertain risk of bias. Analysis demonstrated that anti-reflux surgery was associated with superior short-term quality of life compared to PPI (Std mean difference =  - 0.51, 95%CI  - 0.63, - 0.40, I² = 0%) however short-term symptom control was not significantly superior (RR = 0.75, 95%CI 0.47, 1.21, I² = 82%). A proportion of patients undergoing operative treatment continue PPI treatment (28%). Robotic and laparoscopic fundoplication outcomes were similar. Compared to total fundoplication, partial fundoplication was associated with higher rates of prolonged PPI usage (RR = 2.06, 95%CI 1.08, 3.94, I² = 45%). There was no statistically significant difference for long-term symptom control (RR = 0.94, 95%CI 0.85, 1.04, I² = 53%) or long-term dysphagia (RR = 0.73, 95%CI 0.52, 1.02, I² = 0%). Ien, minimal dissection during fundoplication was associated with lower reoperation rates than maximal dissection (RR = 0.21, 95%CI 0.06, 0.67).

CONCLUSIONS

The available evidence regarding the optimal treatment of GERD often suffers from high risk of bias. Additional high-quality randomized control trials may further inform surgical decision making in the treatment of GERD.

Intermittent concurrent use of clopidogrel and proton pump inhibitors did not increase risk of adverse clinical outcomes in Chinese patients with coronary artery disease

BACKGROUND

Proton pump inhibitors (PPIs) are frequently prescribed to patients with coronary heart disease (CHD) under antiplatelet therapy to prevent gastrointestinal (GI) bleeding. However, its clinical impact is still under debate, especially in Asian population. This study was undertaken to explore the effects of concurrent use of clopidogrel and PPIs on the clinical outcomes in Chinese patients with CHD in secondary prevention.

METHODS

A single-center retrospective study was conducted in 638 patients with CHD on consecutive clopidogrel therapy for at least 1 year. After 18-month follow-up, adverse clinical events were collected. Cox regression was used to calculate hazard ratios (HR) and 95% confidence interval (CI) for the effect of PPI use on the outcomes. A total of 638 patients were recruited from 2014 to 2015 in this study, among whom 201 were sustained PPI users, 188 were intermittent PPI users and the remaining 249 were non-PPI users.

RESULTS

Compared with sustained PPI users, intermittent use of PPIs was associated with a lower risk of stroke, major adverse cardiac events (MACE) and net adverse clinical event (NACE) (stroke: adjusted HR: 0.109, 95% CI 0.014-0.878, p = 0.037; MACE: adjusted HR: 0.293, 95% CI 0.119-0.722; p = 0.008; NACE: adjusted HR: 0.357, 95% CI 0.162-0.786, p = 0.011). Subgroup analysis further revealed the benefit of intermittent PPI use was significant in male CHD patients over 60 years old, with hypertension or chronic kidney disease, and undergoing percutaneous coronary intervention during hospitalization.

CONCLUSION

The current findings suggest that the intermittent concurrent use of PPIs and clopidogrel is not associated with an increased risk of 18-month adverse clinical outcomes, and intermittent use of PPIs is associated with a lower rate of MACE and NACE.

Proton pump inhibitor utilisation and potentially inappropriate prescribing analysis: insights from a single-centred retrospective study

OBJECTIVES

This study aimed to characterise the prescribing patterns and evaluate the appropriateness of the prescribed proton pump inhibitors (PPIs) in adult patients via a review of electronic medical records in a single-centred hospital.

DESIGN

All patients admitted to the outpatient department of Jinshan Hospital, Fudan University, Shanghai, between 1 January 2018 and 31 December 2018 were evaluated. Individuals aged 18 years or above and with at least one dispensing for PPIs were identified as PPI users. New PPI users were defined as a subject who did not receive any dispensing for PPIs in the year prior to the index date. Baseline characteristics of PPI users and their therapies were described by treatment indication, economic indicators and co-prescription, overall and separately.

SETTING

The prescription database was retrieved from the hospital information system of Jinshan Hospital, Fudan University.

RESULTS

Among 18 435 identified PPI users in 2018, 14 219 patients (aged 18 years or above) who had at least one dispensing PPIs were new users (77%), and among them, men accounted for 47%. The mean treatment duration was 23 days. Omeprazole was the most commonly prescribed drug. PPIs are inappropriately prescribed in 50% (13 589/25 850) of prescriptions. Prescription appropriateness analysis indicated that the unapproved indications for PPI new users accounted for 47%; among them, the proportion of gastritis diagnosis was 34%. The proportion of PPI new users with co-prescription of glucocorticosteroids (GCs) who have risk factors accounted for 24% and lower than other co-prescription. A majority of PPI users (73%) reported high-dose PPI prescription. The defined daily dose of oral pantoprazole was the highest, and injectable omeprazole had the highest defined daily cost. In contrast, only the drug utilisation index value of oral esomeprazole was less than 1.0.

CONCLUSION

The results indicate the challenge of PPI use was accompanied by unapproved indications, frequent inappropriate co-prescription with GCs and excessive dosages. Efforts should be paid to promote rational use and ensure the choice of suitable PPI therapy in the future.

Potentially Inappropriate Medication Use in Older Hospitalized Patients with Type 2 Diabetes: A Cross-Sectional Study

Background: Older patients with type 2 diabetes mellitus (T2DM) are at greater risk of receiving potentially inappropriate medications (PIM) during hospitalization which may result in adverse outcomes. Aim: To evaluate the extent of PIM use in the older population with T2DM during hospitalization in a tertiary care hospital in India. Methods: A cross-sectional study was carried out from August 2019 to January 2020 in a tertiary care teaching hospital among the older population (aged ≥ 65 years) hospitalized with T2DM. Medications prescribed during hospitalization were reviewed following Beers Criteria 2019 to identify the extent of polypharmacy and PIM use. Binary logistic regression was applied to determine the factors associated with PIM use. Results: The mean age of the 150 patients hospitalized with T2DM was 68.85 ± 5.51 years, most of whom were men (54.7%). The participants had at least four comorbidities and were receiving an average of nine medications per day; the median length of hospital stay was 8 days (interquartile range (IQR): 4-19 days). Overall, three quarters (74%) of the participants had at least one PIM prescribed during their hospitalization as per Beers Criteria. Significant factors associated with the use of PIM during hospitalization are patients taking a higher number of medications (odds ratio (OR): 7.85, 95% CI 1.49-41.10), lower creatinine clearance values (OR: 12.90, 95% CI 2.81-59.28) and female patients (OR: 2.29; 95% CI: 1.05-4.97). Conclusions: PIM use is frequently observed in older T2DM patients during hospitalization. Polypharmacy, reduced renal function and female gender are associated with higher PIM use. Engaging clinical pharmacists in evaluating medication appropriateness can improve the outcomes of older patients.

The association between use of proton-pump inhibitors and excess mortality after kidney transplantation: A cohort study

BACKGROUND

Chronic use of proton-pump inhibitors (PPIs) is common in kidney transplant recipients (KTRs). However, concerns are emerging about the potential long-term complications of PPI therapy. We aimed to investigate whether PPI use is associated with excess mortality risk in KTRs.

METHODS AND FINDINGS

We investigated the association of PPI use with mortality risk using multivariable Cox proportional hazard regression analyses in a single-center prospective cohort of 703 stable outpatient KTRs, who visited the outpatient clinic of the University Medical Center Groningen (UMCG) between November 2008 and March 2011 (ClinicalTrials.gov Identifier NCT02811835). Independent replication of the results was performed in a prospective cohort of 656 KTRs from the University Hospitals Leuven (NCT01331668). Mean age was 53 ± 13 years, 57% were male, and 56.6% used PPIs. During median follow-up of 8.2 (4.7-9.0) years, 194 KTRs died. In univariable Cox regression analyses, PPI use was associated with an almost 2 times higher mortality risk (hazard ratio [HR] 1.86, 95% CI 1.38-2.52, P < 0.001) compared with no use. After adjustment for potential confounders, PPI use remained independently associated with mortality (HR 1.68, 95% CI 1.21-2.33, P = 0.002). Moreover, the HR for mortality risk in KTRs taking a high PPI dose (>20 mg omeprazole equivalents/day) compared with patients taking no PPIs (HR 2.14, 95% CI 1.48-3.09, P < 0.001) was higher than in KTRs taking a low PPI dose (HR 1.72, 95% CI 1.23-2.39, P = 0.001). These findings were replicated in the Leuven Renal Transplant Cohort. The main limitation of this study is its observational design, which precludes conclusions about causation.

CONCLUSIONS

We demonstrated that PPI use is associated with an increased mortality risk in KTRs, independent of potential confounders. Moreover, our data suggest that this risk is highest among KTRs taking high PPI dosages. Because of the observational nature of our data, our results require further corroboration before it can be recommended to avoid the long-term use of PPIs in KTRs.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02811835, NCT01331668.

Proton Pump Inhibitor Use Before ICU Admission Is Not Associated With Mortality of Critically Ill Patients

Some studies have shown that the long-term use of proton pump inhibitors (PPIs) is associated with many adverse events that may increase mortality; however, the relationship between premorbid PPI use and in-hospital mortality has yet to be validated in critically ill patients. Therefore, we performed this study to determine whether the preadmission use of PPIs is associated with mortality in patients admitted to the intensive care unit. This was a retrospective study with a large and freely accessible database in critical-care medicine (the Multiparameter Intelligent Monitoring in Intensive Care III project). The clinical data and outcomes of 17 473 patients, consisting of 1895 in the PPI group, 514 in the H₂ -receptor antagonist group, and 15 064 control subjects, were collected during their hospital stay. The study outcome was in-hospital mortality. A total of 17 473 patients were included in our study. PPI use was associated with significantly increased in-hospital mortality in the original model without adjustment for any parameters (odds ratio 1.19; 95%CI 1.03-1.38; P = .02). However, after adjustments had been made for age, sex, Elixhauser score, Simplified Acute Physiology Score, laboratory results, vasopressor use, ventilator use, and other parameters, PPIs were not associated with significantly increased in-hospital mortality (odds ratio 1.04; 95%CI 0.87-1.26; P = .614). In the subgroup analysis among patients with renal or liver disease, we still found that PPIs were not associated with a significant increase in in-hospital mortality. We found no association between PPI use before ICU admission and increased in-hospital mortality in critically ill patients compared with control subjects.

Use of proton pump inhibitors is associated with an increase in adverse cardiovascular events in patients with hemodialysis: Insight from the kids registry

BACKGROUND

Proton pump inhibitors (PPIs) are known to increase the risk of mortality and cardiovascular events in the general population. However, in patients with maintenance hemodialysis, PPI effects are under investigated.

METHODS

We analyzed the risk of PPIs for cardiovascular events using the Kagoshima Dialysis (KIDS) registry, a prospective, multicenter, observational study in patients with maintenance hemodialysis in Japan.

RESULTS

In all, 531 patients were enrolled from June 2015 to December 2018. One-year follow-up data were available for 376 patients (Use of PPIs at baseline (PPI group): 217 patients and without PPIs (No PPI group): 159 patients). The incidence of a composite outcome (all-cause mortality, non-fatal myocardial infarction, or non-fatal stroke) was higher in patients in the PPI group than the No PPI group (15.2% vs. 4.4%; hazard ratio (HR): 3.65, 95% confidence interval (CI): 1.61-8.23, P = 0.002). In the multivariate analysis, even after adjustment for covariates, the use of PPIs was an independent risk factor for a composite outcome (HR: 2.38, 95% CI: 1.02-5.54, P = 0.045). We performed propensity score matching analysis as a sensitivity analysis, showing a consistent result. The incidence of bleeding showed no difference between the two groups (15.7% vs. 11.3%; HR: 1.46, 95% CI: 0.83-2.59, P = 0.19).

CONCLUSIONS

These results indicate that the use of PPIs in patients with maintenance hemodialysis might increase mortality and cardiovascular events without decreasing the risk of bleeding. Therefore, it should always be analyzed if a patient truly needs PPIs.

Assessment and treatment of older individuals with COVID 19 multi-system disease: Clinical and ethical implications

Covid-19 infection is a multisystem disease more frequent in older individuals, especially in those with multiple chronic diseases. This multimorbid and frail population requires attention and a personalized comprehensive assessment in order to avoid the occurrence of adverse outcomes. As other diseases, the COVID-19 presentation in older patients is often atypical with less severe and unspecific symptoms. These subjects both at home and during hospitalization suffer isolation and the lack of support of caregivers. The geriatric care in COVID-19 wards is often missing. The application of additional instruments would be necessary to facilitate and personalize the clinical approach, not only based on diseases but also on functional status. This narrative review starts from diagnostic evaluation, continues with adapted pharmacologic treatment and ends with the recovery phase targeting the nutrition and physical exercise. We developed a check-list of respiratory, gastro-intestinal and other less-specific symptoms, summarized in a table and easily to be filled-up by patients, nurses and general practitioners. As second step, we reported the clinical phases of this disease. Far to be considered just viral infective and respiratory, this disease is also an inflammatory and thrombotic condition with frequent bacterial over-infection. We finally considered timing and selection of treatment, which depend on the disease phase, co-administration of other drugs and require the monitoring of renal, liver and cardiac function. This underlines the role of age not just as a limitation, but also an opportunity to increase the quality and the appropriateness of multidisciplinary and multidimensional intervention in this population.

The Clinician's Guide to Proton Pump Inhibitor Related Adverse Events

A substantial volume of literature exists linking proton pump inhibitor (PPI) use with a multitude of serious adverse events. There is uncertainty, however, over whether these associations are clinically important. Excessive concern about PPI-related adverse events may leave patients at risk of harm by leaving acid-related upper gastrointestinal disease untreated. Conversely, the risk of treatments may outweigh the benefits if any of the purported adverse events are directly caused by PPI use; this is of particular concern where indications for PPI use are not present. In this paper, we review the studies which have reported associations between adverse events and PPI use, discuss the proposed mechanisms of action, grade the confidence in whether these associations are truly causal, and provide advice regarding balancing the benefits of PPI use against their possible harms.

Sustained proton pump inhibitor deprescribing among dyspeptic patients in general practice: a return to self-management through a programme of education and alginate rescue therapy. A prospective interventional study

Background

Dyspepsia guidelines recommend that patients treated with proton pump inhibitors (PPIs) should step down to the lowest effective dose or return to self-care, but rebound hyperacidity can make this difficult. Many patients continue on PPIs in the long term, which may lead to safety and financial implications.

Aim

To determine if a nurse-led educational support programme and rescue therapy for rebound symptoms can help patients achieve a sustained reduction in PPI use.

Design & setting

A prospective interventional study was conducted at 26 surgeries across the UK.

Method

Adult patients, treated with PPIs for ≥2 consecutive months with an active repeat prescription, were invited to a 20-minute dyspepsia clinic appointment with a trained nurse adviser. An action plan to reduce and/or stop their PPI usage was agreed and alginate supplied for the self-management of rebound symptoms. After 12 months, PPI status was reviewed and prescribing cost savings calculated.

Results

After 12 months, 75.1% of 6249 eligible patients stepped down or off PPIs (35.3% stepped off; 5.0% stepped down then off; 34.8% stepped down only), while 8.7% of patients had reverted to their original PPI dose. PPI prescriptions fell from 89 915 to 45 880 and alginate prescriptions increased from 2405 to 6670. An average of 1.7 bottles (500 ml each) of alginate were used per patient who stepped down or off. Estimated annual cost-saving on prescriptions was £31 716.30.

Conclusion

A programme of education and short-term rebound symptom management helped the majority of patients to successfully step down or off PPIs, significantly reducing the potential risks associated with chronic therapy.

Proton pump inhibitor use increases mortality and hepatic decompensation in liver cirrhosis

BACKGROUND

Proton pump inhibitors (PPIs) are widely prescribed, often without clear indications. There are conflicting data on its association with mortality risk and hepatic decompensation in cirrhotic patients. Furthermore, PPI users and PPI exposure in some studies have been poorly defined with many confounding factors.

AIM

To examine if PPI use increases mortality and hepatic decompensation and the impact of cumulative PPI dose exposure.

METHODS

Data from patients with decompensated liver cirrhosis were extracted from a hospital database between 2013 to 2017. PPI users were defined as cumulative defined daily dose (cDDD) ≥ 28 within a landmark period, after hospitalisation for hepatic decompensation. Cox regression analysis for comparison was done after propensity score adjustment. Further risk of hepatic decompensation was analysed by Poisson regression.

RESULTS

Among 295 decompensated cirrhosis patients, 238 were PPI users and 57 were non-users. PPI users had higher mortality compared to non-users [adjusted HR = 2.10, (1.20-3.67); P = 0.009]. Longer PPI use with cDDD > 90 was associated with higher mortality, compared to non-users [aHR = 2.27, (1.10-5.14); P = 0.038]. PPI users had a higher incidence of hospitalization for hepatic decompensation [aRR = 1.61, (1.30-2.11); P < 0.001].

CONCLUSION

PPI use in decompensated cirrhosis is associated with increased risk of mortality and hepatic decompensation. Longer PPI exposure with cDDD > 90 increases the risk of mortality.

Proton Pump Inhibitors Are Associated With Minimal and Overt Hepatic Encephalopathy and Increased Mortality in Patients With Cirrhosis

Minimal hepatic encephalopathy (MHE) is a subclinical cognitive impairment frequently observable in patients with cirrhosis. Proton pump inhibitors (PPIs) can contribute to small-bowel bacterial overgrowth, but no study has investigated the link between PPIs and MHE. We investigated the relationship between MHE and PPI use as well as the role of PPI use in the development of overt HE and survival. Consecutive patients with cirrhosis (n = 310) were included in the study and followed up for 14.1 ± 12.3 months. At entry, MHE was diagnosed when the Psychometric Hepatic Encephalopathy Score was ≤-4. Data were analyzed by logistic regression for the factors associated with MHE and by time-related models for overt HE development and survival. At inclusion, 131 out of 310 patients with cirrhosis (42%) were affected by MHE. One hundred and twenty-five patients (40%) were using PPIs. The variables independently associated with the presence of MHE were PPI use, previous overt HE, low albumin, low sodium, and age. During follow-up, the development of overt HE was higher (64% versus 25%, P < 0.001) and overall survival lower (41% versus 81%, P < 0.001) in PPI users than in nonusers. Variables independently associated with the development of overt HE were PPIs, history of overt HE, low albumin, MHE, and age, while variables independently associated with mortality were PPIs, development of overt HE, Model for End-Stage Liver Disease score, low sodium, and age. Conclusion: The study identifies a potentially removable factor associated with the presence of MHE and related to the development of overt HE and survival in patients with liver cirrhosis.

Real-World Relationship Between Proton Pump Inhibitors and Cerebro-Cardiovascular Outcomes Independent of Clopidogrel

Previous studies have provided established evidence on adverse outcomes of the coadministration of proton pump inhibitors (PPIs) and clopidogrel, whereas cerebro-cardiovascular outcomes of PPI use in the absence of clopidogrel therapy remain controversial.In this study, we aimed to assess the association between PPIs and cerebro-cardiovascular outcomes independent of clopidogrel.Systematic searches were conducted in the Cochrane Library, PubMed, and Embase databases for all relevant studies up to August 2018. Odds ratios (ORs) with its 95% confidence intervals (CIs) were abstracted and pooled using the random-effects model.A total of 14 observational studies (13 cohort studies and 1 case-control study) were identified. Compared with non-PPI users, PPI users experienced higher risks of stroke (OR: 1.22, 95% CI: 1.08-1.36), myocardial infarction (MI; OR: 1.23, 95% CI: 1.14-1.32), cardiovascular death (OR: 1.83, 95% CI: 1.69-1.98), and major adverse cardiovascular events (MACEs; OR: 1.22, 95% CI: 1.05-1.40) independent of clopidogrel use, but not all-cause death (OR: 1.50, 95% CI: 0.99-2.25). In the subgroup analysis, PPI alone was associated with significant risks of new-onset MI (OR: 1.23, 95% CI: 1.13-1.35) and stroke (OR: 1.17, 95% CI: 1.05-1.30) in patients without previous MI or stoke and recurrent MI (OR: 1.24, 95% CI: 1.02-1.51) and stroke (OR: 1.36, 95% CI: 1.19-1.55) risks in patients with a previous MI.Based on current publications, PPI use seems to be associated with increased risks of stroke, MI, cardiovascular death, and MACEs independent of clopidogrel. Greater caution should be therefore exercised while considering its clinical benefits and further investigate any causal relationships.

Increased Metabolic Benefit for Obese, Elderly Patients Undergoing Roux-en-Y Gastric Bypass vs Sleeve Gastrectomy

PURPOSE

We sought to assess outcomes of laparoscopic sleeve gastrectomy (LSG) vs laparoscopic Roux-en-Y gastric bypass (LRYGB) in a cohort of morbidly obese, elderly patients.

MATERIALS AND METHODS

Retrospective review was conducted of all patients age 60 years or greater undergoing LSG or LRYGB at our institution between 2007 and 2014.

RESULTS

A total of 134 patients who underwent LSG (n = 65) or LRYGB (n = 69) were identified. Groups were similar with respect to age (64 years, range 60-75 years), BMI (44.0 ± 6.1), and ASA score (91% ≥ ASA 3). There were no differences in major post-operative complications (3, 4.7% LSG vs 4, 5.8% LRYGB, p = 0.75). Median follow-up was 39 months (IQR 14-64 months) with no patients lost to follow-up. Patients undergoing LRYGB had improvement in each of diabetes mellitus 2 (DM2), hypertension (HTN), hyperlipidemia (HL), and gastroesophageal reflux disease (GERD) as well as a significant decrease in insulin use (16/47, 34.0% pre-operatively vs 7/47, 15.2% post-operatively; p = 0.03). Patients undergoing LSG had improvement in DM2 and HTN but not in HL or GERD; there was no reduction in insulin dependence. Weight loss was not significantly different between groups; mean percent total weight loss at 36 months was 26.9 ± 9.0% in the LSG group and 23.9 ± 9.3% in the LRYGB group, p = 0.24.

CONCLUSIONS

Both LSG and RYGB can be safely performed on morbidly obese, elderly adults. At intermediate follow-up, there is an increased metabolic benefit for elderly patients undergoing LRYGB over LSG.

Proton pump inhibitor use and cancer mortality

Proton pump inhibitors (PPIs) are commonly used as a supplement to cancer therapy. Yet, their effect on cancer mortality is largely unknown. Using data from Danish nationwide registries and Cox models regressing of both propensity scores and drug use, we estimated hazard ratios (HRs) with 95% confidence intervals (CIs) for cancer-specific and noncancer death among PPI users (≥2 prescriptions within six months after diagnosis; n = 36,066) compared with nonusers (<2 prescriptions, n = 311,853) or users of histamine H₂ -receptor antagonists (H₂ RA; n = 5,152). Adjusted HRs for cancer-specific mortality among postdiagnostic PPI users as compared with nonusers or H₂ RA users were 1.29 (95% CI, 1.27-1.32) and 1.15 (95% CI, 1.10-1.20), respectively. HRs for cancer mortality associated with PPI use were highest for ovarian (1.35; 95% CI, 1.20-1.52) and lowest for esophageal cancer (0.91; 95% CI, 0.81-1.04). The associations were stronger among new PPI users after cancer diagnosis, indicating potential confounding. To test the effect of PPIs on tumor growth in a model system free for confounding factors, we investigated the effect of pantoprazole on tumor growth in mice. Pantoprazole (5 mg/kg/day) enhanced tumor growth (p = 0.033) and reduced the antitumor activity of gemcitabine (p = 0.008) in fibrosarcoma-bearing Balb/c mice, but not in immunodeficient Balb/c nude mice. In breast carcinoma-bearing FVB/N mice, pantoprazole had no effect on tumor growth alone but it reduced the life-prolonging effect of doxorubicin significantly (p = 0.007). Taken together, these data raise concerns about the increasing use of PPIs and calls for further studies addressing their safety among cancer patients.

Use of proton-pump inhibitors is associated with depression: a population-based study

Treatment with proton-pump inhibitors (PPIs) might be associated with neuropsychological side effects. We examined the association between use of PPIs and depressive symptoms in an elderly population. Mood was assessed by the 30-item Geriatric Depression Scale (GDS) in all 344 inhabitants of Tuscania (Italy) aged 75 years and over, without exclusion criteria; depression was defined by a GDS score ≥11. Use of PPIs was associated with a higher GDS score in linear regression analysis (B = 2.43; 95% CI = 0.49-4.38; p = 0.014) after adjusting; also, use of PPIs was associated with increased adjusted probability of depression in logistic regression (OR = 2.38; 95% CI = 1.02-5.58; p = 0.045). Higher PPIs dosages were associated with increased probability of depression (p for trend = 0.014). This association was independent of the diagnosis of peptic disease, as well as the use of antidepressant medications. No association was found between use of H2-blockers or antacids and the GDS score. Calculation of the population attributable risk indicated that 14% of depression cases could be avoided by withdrawal of PPIs. Use of PPIs might represent a frequent cause of depression in older populations; thus, mood should be routinely assessed in elderly patients on PPIs.

[Proton pump inhibitors and kidney]

Assumed for a long time to be very well tolerated, proton pump inhibitors (PPIs) are widely prescribed for inpatients and outpatients; often beyond their validated indications. Nevertheless, many very varied side effects (pneumopathy, ischemic heart disease, dementia) have been associated with the PPIs during the last decade. Renal toxicity is mainly the occurrence of acute interstitial nephritis (AIN), related to a drug-class effect, involving cellular immunity. AINs, which occur especially in elderly patients, can be difficult to diagnose, with frequently isolated acute kidney injury, appearing with variable delay after the introduction of PPIs. Although sensitive to steroid therapy, patients frequently have an incomplete recovery of the kidney function. Very recently, the risk of chronic kidney disease (CKD) and the risk of progression of CKD among PPIs users have been well demonstrated in several large independent epidemiological studies. It is a low, but a significant side effect because of the millions of PPI prescriptions. Although further studies are needed to investigate the pathophysiological mechanisms leading the use of PPI to CKD, it is appropriate for the physicians to limit PPIs to their correct indications and to monitor renal function during these treatments.

Outcomes From a Pharmacist - led Proton Pump Inhibitor Stewardship Program at a Single Institution

Background: Proton pump inhibitors (PPIs) are effective medications for acid-related disorders; however, they are also overused and may be associated with several adverse effects. A PPI stewardship program was implemented at one institution to combat the overuse of PPIs. Objective: The purpose of this study is to evaluate the effectiveness of an inpatient PPI stewardship program in reducing PPI use, both during hospitalization and upon discharge. Methods: This was a retrospective cohort study of all patients admitted to an internal medicine service at a single institution from March 14, 2016, to August 14, 2016, with an intervention by the PPI stewardship team. The primary objective was to determine the percentage of patients who tolerated inpatient and outpatient PPI discontinuation, or dose de-escalations upon discharge. Secondary objectives included the identification of risk factors for intolerance of PPI discontinuation, the occurrence of gastrointestinal (GI) complications after PPI discontinuation, and the percentage of patients who required "as needed" acid suppressive therapy (AST) with an antacid or histamine-2 receptor antagonist (H2RA) to control their symptoms while hospitalized. Results: During the study time period, 537 patients with an active outpatient prescription for a PPI were admitted to an internal medicine team with 41.0% (n = 220) not meeting criteria for inpatient continuation. Of these patients, 95.9% (n = 211) tolerated inpatient PPI discontinuation, with 83.4% (n = 176) not requiring any "as needed" AST during hospitalization. Upon discharge, 57.1% patients (n = 24 of 42) tolerated PPI discontinuation at 3 months, while 81.8% patients (n = 18 of 22) tolerated PPI dose de-escalations at 3 months. Risk factors for intolerance of inpatient PPI discontinuation were a higher body mass index (BMI) (33.7 vs 30.3 kg/m², P = .046) and longer length of stay (7.0 vs 4.0 days, P = .03), while longer duration of PPI use (9.0 vs 5.5 years, P = 0.03) was identified as a risk factor for intolerance of outpatient PPI discontinuation. One patient experienced reflux esophagitis 2 months after PPI discontinuation. Conclusion: A PPI stewardship program at a single institution resulted in the reduction of inappropriate PPI use in both the inpatient and outpatient settings.

Proton-pump inhibitors: understanding the complications and risks

Proton-pump inhibitors (PPIs) are the most effective therapy for the full spectrum of gastric-acid-related diseases. However, in the past decade, a steadily increasing list of complications following long-term use of PPIs has been reported. Their potent acid-suppressive action induces several structural and functional changes within the gastric mucosa, including fundic gland polyps, enterochromaffin-like cell hyperplasia and hypergastrinaemia, which can be exaggerated in the presence of Helicobacter pylori infection. As discussed in this Review, most associations of PPIs with severe adverse events are not based on sufficient evidence because of confounding factors and a lack of plausible mechanisms. Thus, a causal relationship remains unproven in most associations, and further studies are needed. Awareness of PPI-associated risks should not lead to anxiety in patients but rather should induce the physician to consider the appropriate dosing and duration of PPI therapy, including long-term monitoring strategies in selected groups of patients because of their individual comorbidities and risk factors.

Proton Pump Inhibitors and Cardiovascular Events: A Systematic Review

BACKGROUND

Proton pump inhibitors (PPIs) are a commonly prescribed medication that recent data has linked to an increased risk of cardiovascular morbidity and all cause morbidity. The current study sought to perform a systematic review to investigate the link between PPIs and morbidity and mortality METHODS: A systematic review was carried out as per the PRISMA guidelines, with information databases including Pubmed, Medline, and the Cochrane Review Database. English-language studies of all types published from January 1990 to October 2016 were considered. Dichotomous analysis generating odds ratios was performed using RevMan Version 5.3.

RESULTS

Thirty-seven studies were considered, of which five directly compared the effect of PPI use on mortality and/or cardiovascular morbidity (including 22,427 patients in mortality datasets, and 354,446 patients in morbidity datasets). For patients taking PPIs, all cause mortality (OR 1.68 [95% CI 1.53-1.84], p<0.001) and rate of major cardiovascular events (OR 1.54 [95% CI 1.11-2.13], p=0.01) were significantly higher.

CONCLUSIONS

The current systematic review demonstrates that, in patients using PPIs, there was a significant increase in morbidity due to cardiovascular disease. Careful consideration should be given to the prescription of PPIs while clinical equipoise remains. Further research in the area is required.

Proton Pump Inhibitor Usage and the Risk of Mortality in Hemodialysis Patients

Introduction

Long-term inappropriate proton pump inhibitors use (PPIs) is a matter of concern because of the risks associated with their long-term use in older patients with chronic conditions. The risk of PPI treatment in hemodialysis patients remains unexplored.

Methods

We assessed the relationship between the use of PPIs and the risk of death in hemodialysis patients throughout a retrospective multicenter propensity score–matched study. Information about demographic, hemodialysis treatment, laboratory data, and concomitant medication was obtained from the EuCliD database (Fresenius Medical Care). We studied 1776 hemodialysis patients on PPI therapy compared to 466 patients not receiving PPIs. The resulting population comprising 2 groups of 410 matched patients was studied.

Results

PPI use was associated with hypomagnesemia (Mg <1.8 mg/dl (0.75 mmol/l); odds ratio [OR] = 2.70, 95% confidence interval [CI] = 1.38−5.27, P < 0.01). The exposure to PPIs in the full patient cohort was identified as an independent predictor for all-cause mortality in both univariate (HR = 3.16, 95% CI = 1.69–5.90, P < 0.01) and multivariate (HR = 2.70, 95% CI = 1.38–5.27, P < 0.01) Cox regression models. Moreover PPI use was identified as a predictor of CV mortality (HR = 1.51, 95% CI = 1.05−2.20, P = 0.03) Of the 820 patients matched throughout the propensity score analysis, the hazard ratios for all-cause mortality (HR = 1.412, 95% CI = 1.04–1.93, P = 0.03) and CV mortality (HR = 1.67, 95% CI = 1.03−2.71, P = 0.04) were higher among patients on PPIs versus those not on PPIs.

Conclusion

The study data suggest that the PPI treatment should be regularly monitored and prescribed only when indicated.

Implementation of Global Strategies to Prevent Hospital-Onset Clostridium difficile Infection: Targeting Proton Pump Inhibitors and Probiotics

Background: Proton pump inhibitors (PPIs) have been identified as a significant risk factor for the development of Clostridium difficile infection (CDI). Probiotics given concurrently with antibiotics have been shown to have a moderate impact on preventing CDI. Objective: To evaluate the effectiveness of hospital-wide interventions designed to reduce PPI use and increase probiotics and whether these interventions were associated with a change in the incidence of hospital onset (HO)-CDI. Methods: This retrospective cohort study compared 2 fiscal years: July 2013 to June 2014 (FY14) and July 2014 to June 2015 (FY15). In July of FY15, global educational initiatives were launched targeting PPIs. Additionally, a HO-CDI prevention bundle was added to antibiotic-containing order sets targeting probiotics. Overall PPI use, probiotic use, and incidence of HO-CDI were recorded and compared for each cohort. Charts were also reviewed for patients who developed HO-CDI for the presence and appropriateness of a PPI and presence of probiotics. Results: The interventions resulted in a decrease in PPI use by 14% or 96 doses/1000 patient days (TPD; P = 0.0002) and a reduction in IV PPI use by 31% or 71 doses/TPD ( P = 0.0008). Probiotic use increased by 130% or 126 doses/TPD ( P = 0.0006). The incidence of HO-CDI decreased by 20% or 0.1 cases/TPD ( P = 0.04). Conclusions: A collaborative, multifaceted educational initiative directed at highlighting the risks associated with PPI use was effective in reducing PPI prescribing. The implementation of a probiotic bundle added to antibiotic order sets was effective in increasing probiotic use. These interventions were associated with a decrease in incidence of HO-CDI.

Effectiveness of Interventions to Deprescribe Inappropriate Proton Pump Inhibitors in Older Adults

BACKGROUND

The use of proton pump inhibitors (PPIs) in older adults is high, often inappropriate, and may cause harm. Deprescribing is defined as the reduction, withdrawal, or discontinuation of inappropriate medication.

OBJECTIVE

We conducted a systematic review to determine the effectiveness of interventions to deprescribe inappropriate PPIs in older adults.

METHODS

We searched MEDLINE, PubMed, Embase, the Cochrane Library, ProQuest Dissertations and Theses Global, and Google from inception to January 2017 for randomized and non-randomized studies describing the outcomes of interventions to deprescribe inappropriate PPIs in older adults (mean or median age of ≥65 years). Where available, clinically relevant outcomes were also assessed.

RESULTS

We included 21 articles in our review. Six studies demonstrated effective interventions, 11 were inconclusive, and four were ineffective. Effective interventions included a population-wide education and promotion strategy, academic detailing for general practitioners, and inpatient geriatrician-led deprescribing. Methodological issues limited the interpretation of several studies. Standardization in outcome reporting was lacking, and clinical outcome data were absent. A comparison of intervention effectiveness was not possible because of their heterogeneity, which precluded a meta-analysis.

CONCLUSION

The limited available evidence suggests that some strategies are more successful than others in effectively deprescribing inappropriate PPIs in older adults. However, whether PPI deprescribing translates into better clinical outcomes remains unclear.

Risk of death among users of Proton Pump Inhibitors: a longitudinal observational cohort study of United States veterans

OBJECTIVE

Proton pump inhibitors (PPIs) are widely used, and their use is associated with increased risk of adverse events. However, whether PPI use is associated with excess risk of death is unknown. We aimed to examine the association between PPI use and risk of all-cause mortality.

DESIGN

Longitudinal observational cohort study.

SETTING

US Department of Veterans Affairs.

PARTICIPANTS

Primary cohort of new users of PPI or histamine H2 receptor antagonists (H2 blockers) (n=349 312); additional cohorts included PPI versus no PPI (n=3 288 092) and PPI versus no PPI and no H2 blockers (n=2 887 030).

MAIN OUTCOME MEASURES

Risk of death.

RESULTS

Over a median follow-up of 5.71 years (IQR 5.11-6.37), PPI use was associated with increased risk of death compared with H2 blockers use (HR 1.25, CI 1.23 to 1.28). Risk of death associated with PPI use was higher in analyses adjusted for high-dimensional propensity score (HR 1.16, CI 1.13 to 1.18), in two-stage residual inclusion estimation (HR 1.21, CI 1.16 to 1.26) and in 1:1 time-dependent propensity score-matched cohort (HR 1.34, CI 1.29 to 1.39). The risk of death was increased when considering PPI use versus no PPI (HR 1.15, CI 1.14 to 1.15), and PPI use versus no PPI and no H2 blockers (HR 1.23, CI 1.22 to 1.24). Risk of death associated with PPI use was increased among participants without gastrointestinal conditions: PPI versus H2 blockers (HR 1.24, CI 1.21 to 1.27), PPI use versus no PPI (HR 1.19, CI 1.18 to 1.20) and PPI use versus no PPI and no H2 blockers (HR 1.22, CI 1.21 to 1.23). Among new PPI users, there was a graded association between the duration of exposure and the risk of death.

CONCLUSIONS

The results suggest excess risk of death among PPI users; risk is also increased among those without gastrointestinal conditions and with prolonged duration of use. Limiting PPI use and duration to instances where it is medically indicated may be warranted.

Analysis of medication use by elderly persons with supplemental health insurance plans

Abstract Objective: To analyze the socio-demographic and pharmacotherapeutic profiles of elderly users of a private health plan. Method: A cross-sectional and descriptive study was conducted with 239 elderly users of a private health plan in a medium-size city in the state of São Paulo, Brazil. A structured questionnaire was used for data collection and absolute and relative frequencies were obtained. The pharmacotherapeutic survey estimated the prevalence and average number of medicines used in the 15 days prior to the interview, as well as adherence to treatment. Results: Of the respondents, 79% were female, with a mean age of 73 years. The main health problems reported were: arterial hypertension, rheumatism/arthritis, dyslipidemia and diabetes. A total of 97.1% of the elderly persons used medicine, and the most frequently used classes were for the cardiovascular and digestive systems. An average of 5.9 drugs/elderly person were used and 62.8% of the sample were undergoing polymedication. A total of 11.7% of the sample used medications that were unsuitable for the elderly, 51% had average adherence to medication and 12.1% had poor adherence. Conclusions: The majority of elderly people in the sample were female, lived with relatives and had a higher-level education. Despite the use of polymedication and the presence of multiple comorbidities, the percentage of elderly persons with low adherence to treatment was lower than that found in other studies. A high level of education and purchasing power, which facilitated the access to medication of the elderly patients under study, may be important predictors of adherence to treatment. The results support maintaining a model of care for the elderly centered on the treatment of diseases and pharmacotherapy.

Use of Proton-Pump Inhibitors Predicts Heart Failure and Death in Patients with Coronary Artery Disease

OBJECTIVES

Proton-pump inhibitors (PPIs) seem to increase the incidence of cardiovascular events in patients with coronary artery disease (CAD), mainly in those using clopidogrel. We analysed the impact of PPIs on the prognosis of patients with stable CAD.

METHODS

We followed 706 patients with CAD. Primary outcome was the combination of secondary outcomes. Secondary outcomes were 1) acute ischaemic events (any acute coronary syndrome, stroke, or transient ischaemic attack) and 2) heart failure (HF) or death.

RESULTS

Patients on PPIs were older [62.0 (53.0-73.0) vs. 58.0 (50.0-70.0) years; p = 0.003] and had a more frequent history of stroke (4.9% vs. 1.1%; p = 0.004) than those from the non-PPI group, and presented no differences in any other clinical variable, including cardiovascular risk factors, ejection fraction, and therapy with aspirin and clopidogrel. Follow-up was 2.2±0.99 years. Seventy-eight patients met the primary outcome, 53 developed acute ischaemic events, and 33 HF or death. PPI use was an independent predictor of the primary outcome [hazard ratio (HR) = 2.281 (1.244-4.183); p = 0.008], along with hypertension, body-mass index, glomerular filtration rate, atrial fibrillation, and nitrate use. PPI use was also an independent predictor of HF/death [HR = 5.713 (1.628-20.043); p = 0.007], but not of acute ischaemic events. A propensity score showed similar results.

CONCLUSIONS

In patients with CAD, PPI use is independently associated with an increased incidence of HF and death but not with a high rate of acute ischaemic events. Further studies are needed to confirm these findings.

Polypharmacy and potentially inappropriate medications: a cross-sectional analysis among 451 nursing homes in France

PURPOSE

The quality of drug therapy is an important issue for nursing homes. This study aimed to assess the prevalence of polypharmacy and potentially inappropriate medications (PIMs) in a large sample of nursing home residents by using the data recorded during the preparation of pill dispensers.

METHODS

This is a cross-sectional study that included 451 nursing homes across France. Information about the medications received by the 30,702 residents (73.8% women) living in these nursing homes was extracted from the system that assists in the preparation of pill dispensers in pharmacies. The anonymized database included age, sex, and medications prescribed to residents, as well as nursing home characteristics (capacity, legal status). Factors associated with excessive polypharmacy (≥10 different drugs) and PIMs according to the Laroche list were studied using multilevel regression models.

RESULTS

The average number of drugs prescribed was 6.9 ± 3.3, and excessive polypharmacy concerned 21.1% of the residents (n = 6468). According to the Laroche list, 47.4% of residents (n = 14,547) received at least one PIM. Benzodiazepines (excessive doses, long-acting benzodiazepines, and combination of benzodiazepines) and anticholinergic medications (hydroxyzine, cyamemazine, alimemazine) accounted for a large part of PIMs. Individual characteristics (age, gender) influenced the risk of receiving PIMs whereas nursing home characteristics (capacity, legal status) influenced the risk of excessive polypharmacy.

CONCLUSIONS

This study shows that polypharmacy and PIMs remain highly prevalent among nursing home residents. Main PIMs concerned psychotropic and anticholinergic medications.