Lack of Association Between Proton Pump Inhibitor Use and Cognitive Decline

Highly prevalent geriatric medications and their effect on β-amyloid fibril formation

BACKGROUND

The unprecedented increase in the older population and ever-increasing incidence of dementia are leading to a "silver tsunami" in upcoming decades. To combat multimorbidity and maintain daily activities, elderly people face a high prevalence of polypharmacy. However, how these medications affect dementia-related pathology, such as Alzheimer's β-amyloid (Aβ) fibrils formation, remains unknown. In the present study, we aimed to analyze the medication profiles of Alzheimer's disease (AD; n = 124), mild cognitive impairment (MCI; n = 114), and non-demented (ND; n = 228) patients to identify highly prevalent drugs and to determine the effects of those drugs on Aβ fibrils formation.

METHODS

Study subjects (≥ 65 years) were recruited from an academic geriatric practice that heavily focuses on memory disorders. The disease state was defined based on the score of multiple cognitive assessments. Individual medications for each subject were listed and categorized into 10 major drug classes. Statistical analysis was performed to determine the frequency of individual and collective drug classes, which are expressed as percentages of the respective cohorts. 10 µM monomeric β-amyloid (Aβ) 42 and fibrillar Aβ (fAβ) were incubated for 6-48 h in the presence of 25 µM drugs. fAβ was prepared with a 1:10 ratio of Aβ42 to Aβ40. The amount of Aβ fibrils was monitored using a thioflavin T (Th-T) assay. Neuronal cells (N2A and SHSY-5Y) were treated with 25 µM drugs, and cell death was measured using a lactose dehydrogenase (LDH) assay.

RESULTS

We noticed a high prevalence (82-90%) of polypharmacy and diverse medication profiles including anti-inflammatory (65-77%), vitamin and mineral (64-72%), anti-cholesterol (33-41%), anti-hypersensitive (35-39%), proton pump inhibitor (23-34%), anti-thyroid (9-21%), anti-diabetic (5-13%), anti-constipation (9-11%), anti-coagulant (10-13%), and anti-insomnia (9-20%) drugs in the three cohorts. Our LDH assay with 18 highly prevalent drug components showed toxic effects of Norvasc, Tylenol, Colace, and Plavix on N2A cells, and of vitamin D and Novasc on SH-SY5Y cells. All these drugs except Colace significantly reduced the amount of Aβ fibril when incubated with Aβ42 for a short period (6 h). However, Lipitor, vitamin D, Levothyroxine, Prilosec, Flomax, and Norvasc prominently reduce the amount of fibrils when incubated with monomeric Aβ42 for a longer period (48 h). Furthermore, our disaggregation study with fAβ showed consistent results for cholecalciferol (vitamin D), omeprazole (Prilosec), clopidogrel hydrogensulfate (Flomax), levothyroxine, and amlodipine (Norvasc). The chemical structures of these four efficient molecules contain polyphenol components, a characteristic feature of the structures of polyphenolic inhibitors of Aβ fibrillation.

CONCLUSION

A higher polypharmacy incidence was observed in an elderly population of 228 ND, 114 MCI, and 124 AD patients. We found that several highly recommended drug components, including vitamin D3, Levothyroxine, Prilosec, Flomax, and Norvasc, efficiently reduce the amount of fibrils formed by monomeric Aβ42 and existing preformed Aβ fibrils in vitro. However, only Levothyroxine was able to prevent Aβ-mediated toxicity to SH-SY5Y cells. Our study suggested that these drugs likely function as polyphenolic inhibitors of Aβ.

Proton Pump Inhibitors and Cognitive Health: Review on Unraveling the Dementia Connection and Co-morbid Risks

Dementia, an international health issue distinguished by the impairment of daily functioning due to cognitive decline, currently affects more than 55 million people worldwide, with the majority residing in low-income and middle-income countries. Globally, dementia entails significant economic burdens in 2019, amounting to a cost of 1.3 trillion US dollars. Informal caregivers devote considerable hours to providing care for those affected. Dementia imposes a greater caregiving and disability-adjusted life-year burden on women. A recent study has established a correlation between prolonged Proton Pump Inhibitor (PPI) usage and dementia, in addition to other neurodegenerative conditions. PPIs are frequently prescribed to treat peptic ulcers and GERD (gastroesophageal reflux disease) by decreasing stomach acid secretion. They alleviate acid-related symptoms through the inhibition of acid-secreting H+-K+ ATPase. In a number of observational studies, cognitive decline and dementia in the elderly have been linked to the use of PPIs. The precise mechanism underlying this relationship is unknown. These drugs might also alter the pH of brain cells, resulting in the accumulation of amyloid-beta (Aβ) peptides and the development of Alzheimer's disease (AD). Despite the compelling evidence supporting the association of PPIs with dementia, the results of studies remain inconsistent. The absence of a correlation between PPI use and cognitive decline in some studies emphasizes the need for additional research. Chronic PPI use can conceal underlying conditions, including cancer, celiac disease, vitamin B12 deficiency, and renal injury, highlighting dementia risk and the need for further investigations on cognitive health.

Proton Pump Inhibitor Use and Cognitive Function in the Boston Puerto Rican Health Study

BACKGROUND

There is a lack of consensus among studies on the association between proton pump inhibitor (PPI) use and cognitive impairment. This association is not well studied among minority populations, including among Puerto Ricans. Therefore, we sought to examine this association among Boston-area Puerto Ricans.

METHODS

The Boston Puerto Rican Health Study is an ongoing longitudinal cohort that enrolled 1499 Boston-area Puerto Rican adults, aged 45-75 years at baseline. Complete outcome and exposure data was available for 1290 baseline participants. Covariate-adjusted linear regression and linear mixed effects models were used to examine the association between PPI use, and global cognition, executive function, and memory cross-sectionally and longitudinally over ~12.7 years of follow-up. Furthermore, we examined the cross-sectional association between long-term PPI use (continuous use of ~6.2 years) and global cognition, executive function, and memory.

RESULTS

Among 1 290 participants at baseline, 313 (24.3%) self-reported PPI use. Baseline PPI use was not associated with baseline global cognition, executive function, or memory. Baseline PPI use also did not alter the trajectory of global cognition, executive function, or memory over ~12.7 years of follow-up. Long-term PPI use was not associated with global cognition, executive function, or memory over ~12.7 years of follow-up.

CONCLUSION

In this study of Boston-area Puerto Ricans, we did not observe an association between PPI use and global cognition, executive function, or memory either cross-sectionally or over 12.7 years of follow-up.

Proton pump inhibitors and dementia: what association?

Several recent studies have suggested an association between proton pump inhibitors and the development of cognitive changes.

Objective

To assess the existence of this association.

Methods

A comprehensive literature search was conducted including guidelines, meta-analyses, systematic reviews, observational and experimental studies published between February 2011 and February 2021.

Results

The initial research identified 393 articles, 28 of which were included: 8 systematic reviews, 1 clinical trial, 15 observational studies, 3 case-control studies, and 1 cross-sectional observational study.

Conclusions

Most studies classified with the highest level of evidence found no statistically significant association between the use of proton pump inhibitors and the development of cognitive impairment or dementia.

Do proton pump inhibitors increase the risk of dementia? A systematic review, meta-analysis and bias analysis

AIM

Previous studies on the association between proton pump inhibitor (PPI) intake and the increased risk of dementia has shown discrepancies in their conclusions. We aimed to provide updated evidence based on extensive bias assessments and quantitative sensitivity analyses.

METHODS

We searched the databases PubMed, EMBASE, SCOPUS, CENTRAL and clinicaltrials.gov for prospective studies that examined an association between PPI use and dementia, up to February 2022. Each study was assessed using the Cochrane risk of bias assessment tools for non-randomized studies of interventions (ROBINS-I) or randomized trials (RoB2). Pooled risk ratios (RRs) and 95% prediction intervals were computed using random-effects models. Sensitivity analyses were adjusted for small-study bias.

RESULTS

We included nine observational studies with 204 108 dementia cases in the primary analysis on the association between PPI use vs. non-use and dementia, and the RR was 1.16 (95% CI = 1.00; 1.35). After adjusting for small-study bias by Copas selection model and Rücker's shrinkage procedure, the RR was 1.16 (1.02; 1.32) and 1.15 (1.13; 1.17), respectively. A subgroup analysis of PPI use vs. non-use regarding Alzheimer's disease risk yielded an RR of 1.15 (0.89; 1.50). The secondary analysis on the risk of dementia by use of PPI vs. histamine-2 receptor antagonist showed an RR of 1.03 (0.66; 1.62).

CONCLUSION

This meta-analysis provided no clear evidence for an association between PPI intake and the risk of dementia. Due to discrepancies in sensitivity analyses, however, some risk of dementia by PPI use cannot be ruled out. Since an unequivocal conclusion is still pending, further research is warranted.

Chronic omeprazole use in the elderly is associated with decreased risk of dementia and cognitive decline

BACKGROUND

The association between proton pump inhibitor (PPI) use and increased risk of dementia is controversial.

AIM

Investigating this issue in a large population of community-dwelling elders.

METHODS

Our database was retrospectively searched for all community-dwelling patients aged ≥65 years who newly diagnosed with dementia/cognitive decline (DCD) between January 2002 - December 2012. Receiving ≥11 prescriptions of PPIs/year was categorized as PPI users. Clinical data were collected from the medical files. Risk of DCD in PPI users was analyzed by Cox regression models.

RESULTS

Included 48,632 elders of whom 8,848 were diagnosed with DCD (18.2%). PPI use was documented in 10,507, of whom 1,959 were subsequently diagnosed with DCD (18.6%). Among 38,125 non-PPI users, 6,889 (18.1%) were diagnosed with DCD. The hazard ratio for occurrence of DCD in PPI users compared to non-users was 0.85 (95% CI: 0.81-0.89, P <0.001) in an un-adjusted Cox regression model and 0.83 in a Cox regression model adjusted for age and sex (95% CI: 0.79-0.87, P <0.001). Multivariate Cox regression accounting for background diseases, marital status, and socioeconomic state yielded a hazard ratio of 0.77 (95% CI: 0.73-0.81, P <0.001).

CONCLUSION

PPI use wasn't associated with DCD development in chronic PPI users.

Gastroparesis in Parkinson Disease: Pathophysiology, and Clinical Management

Patients with Parkinson disease (PD) experience a range of non-motor symptoms, including gastrointestinal symptoms. These symptoms can be present in the prodromal phase of the disease. Recent advances in pathophysiology reveal that α-synuclein aggregates that form Lewy bodies and neurites, the hallmark of PD, are present in the enteric nervous system and may precede motor symptoms. Gastroparesis is one of the gastrointestinal involvements of PD and is characterized by delayed gastric emptying of solid food in the absence of mechanical obstruction. Gastroparesis has been reported in nearly 45% of PD. The cardinal symptoms include early satiety, postprandial fullness, nausea, and vomiting. The diagnosis requires an appropriate test to confirm delayed gastric emptying, such as gastric scintigraphy, or breath test. Gastroparesis can lead to malnutrition and impairment of quality of life. Moreover, it might interfere with the absorption of antiparkinsonian drugs. The treatment includes dietary modifications, and pharmacologic agents both to accelerate gastric emptying and relieve symptoms. Alternative treatments have been recently developed in the management of gastroparesis, and their use in patients with PD will be reported in this review.

A pharmacovigilance study of association between proton pump inhibitor and dementia event based on FDA adverse event reporting system data

Proton pump inhibitor (PPI) was widely used around the world. Studies suggested conflicting results between PPI treatment and dementia event. This study examined the association between six PPI agents and dementia event by mining the US FDA Adverse Event Reporting System (FAERS) database from 2004 to 2020. We employed proportional reporting ratio (PRR) and information element (IC) methods to detect the signals of dementia relevant to PPI. We also analyzed characteristics of PPI and positive control reports, compared dementia event between long- and short-duration of PPI treatment. Finally, we identified 2396 dementia cases with PPI treatment. We did not detect significant signal between PPI and dementia event: PRR = 0.98, 95%CI 0.94 to 1.02, IC = −0.03, 95%CI − 0.17 to 0.10, even in gastroesophageal reflux disease cases: PRR = 0.65, 95%CI 0.59 to 0.72, IC = −0.62, 95%CI − 0.97 to − 0.27. No significant differences of dementia event were detected between long- and short- duration groups, the OR (95%CI) of the 3 years, 5 years and 10 years comparison were 0.70 (0.48 to 1.02), 0.72 (0.45 to 1.15) and 1.65 (0.75 to 3.63), respectively. Based on the current FAERS data mining, we discovered no association between PPI use and dementia event, even in long-term PPI therapy case.

Lack of association between proton pump inhibitor use and decline in cognitive performance in the ELSA-Brasil cohort

OBJECTIVE

The study aims to investigate the longitudinal association of use and time of use of proton pump inhibitors (PPIs) with decreased performance in three cognitive tests.

METHODS

Prospective cohort study included 7115 participants with mean age of 58.9 years at baseline (2008-2010) who participated in the second wave (2012-2014) of ELSA-Brasil (average interval between visits = 3.9 years (range: 1.7 to 6.0 years)). Cognitive performance was assessed by tests of memory, phonemic and semantic verbal fluency, and the trail making test, applied to both waves. Associations with the use and time of use of PPIs at baseline were investigated using linear models with mixed effects after adjusting for confounding factors.

RESULTS

At baseline, 7.4% (529) of the participants used PPIs on a regular basis. After all adjustments, the interaction term use of PPI × age was not statistically significant for the cognitive tests evaluated, indicating that the use of PPI at baseline was not associated with a more accelerated decline in cognitive performance between waves. The interaction term PPI use × age was not statistically significant, in any of the categories of medication use time, any of the cognitive function tests evaluated, indicating that PPI use time is not associated with decrease in cognitive scores as the time interval between visits increases.

CONCLUSION

In this cohort middle-aged and elderly adults, after average interval of 3.9 years (relatively short time to detect cognitive decline in a young cohort), the use and time of use of PPIs at the beginning of the study were not associated with a decline in cognitive performance in these tests between visits.

Acid suppressants use and the risk of dementia: A population-based propensity score-matched cohort study

In this population-based propensity score matched (PSM) cohort study, we aimed to investigate the risk of developing dementia with the use of acid suppressants, including proton pump inhibitors (PPIs) and histamine-2 receptor antagonists (H2 antagonists). Cohorts of PPI users (n = 2,778), H2 antagonist users (n = 6,165), and non-users (n = 86,238) were selected from a dataset covering the years 2000 to 2010 in Taiwan’s National Health Insurance Research Database. Patients in the three groups were PSM at a ratio of 1:1 within each comparison cohort (CC). Three CCs were created: (1) PPI users compared to non-users (CC1, n = 2,583 pairs); (2) H2 antagonist users compared to non-users (CC2, n = 5,955 pairs); and (3) PPI users compared to H2 antagonist users (CC3, n = 2,765 pairs). A multivariable robust Cox proportional hazard model was used to estimate the adjusted hazard ratio (aHR) and the 95% confidence interval (CI) for the risk of developing dementia. The multivariable analysis results show that the aHR of developing dementia during the follow-up period was 0.72 (CC1: 95% CI = 0.51–1.03, P = 0.07) for PPI users and 0.95 (CC2: 95% CI = 0.74–1.22, P = 0.69) for H2 antagonist users, when compared to non-users. Between the patients using acid suppressants, there was no difference between PPI and H2 antagonist users in the risk of developing dementia (CC3: aHR = 0.82, 95% CI = 0.58–1.17, P = 0.28). In conclusion, no association was observed between the use of acid suppressants and the risk of developing dementia in any of the three CCs. Further, randomized controlled trials are warranted to confirm this relationship.

Clinical Use of Acid Suppressants and Risk of Dementia in the Elderly: A Pharmaco-Epidemiological Cohort Study

BACKGROUND

Results of studies regarding the potential link between acid suppressant use and dementia risk are inconsistent. This study aimed to evaluate the association of cumulative exposure to histamine 2 receptor antagonists (H2RAs) and proton pump inhibitors (PPIs) with dementia risk in an Asian older cohort aged ≥65 years.

METHODS

Patients initiating H2RA (the H2RA user cohort, n = 21,449) or PPI (the PPI user cohort, n = 6584) and those without prescription for H2RA (the H2RA non-user cohort, n = 21,449) or PPI (the PPI non-user cohort, n = 6584) between 1 January 2000 and 31 December 2005 without a prior history of dementia were identified from Taiwan's National Health Insurance Research Database (NHIRD). The outcome of interest was all-cause dementia. Patients' exposure to H2RAs or PPIs was followed-up from dates of initial prescription to the earliest outcome of incident dementia, death, or the end of 2013. Potential associations between acid suppressant use and dementia risk were analyzed using time-dependent Cox regression estimated hazard ratios (HRs) and 95% confidence intervals (CIs).

RESULTS

After mutual adjustment for H2RA and PPI use and other potential confounders, patients with H2RA use had significantly higher risk of developing dementia as compared to those not treated with H2RAs (adjusted HR, 1.84; 95% CI, 1.49-2.20). Likewise, PPI users had significantly elevated risk of dementia compared to PPI non-users (adjusted HR, 1.42; 95% CI, 1.07-1.84).

CONCLUSIONS

Our results indicate that exposures to H2RAs and PPIs are associated with increased dementia risk.

What is the truth about proton pump inhibitors?

PURPOSE OF REVIEW

This review explores the recent evidence and established scientific literature surrounding proton pump inhibitors in the context of laryngology.

RECENT FINDINGS

Proton pump inhibitors are often associated with gastroenterology; however, they also have a place in laryngology. Several laryngopharyngeal disorders are treated with proton pump inhibitors, though limited evidence regarding effectiveness, dosing and length of treatment exists. With the recent influx of articles reporting possible adverse effects of proton pump inhibitors, the appropriate prescribing of them has come under scrutiny. These reported risks include cancer, stroke, myocardial infarction, kidney disease and cognitive decline. It should be noted though that many of these studies by nature, are fraught with potential confounding. Regardless, clinicians ought to be aware of any risks associated with treatment regimens and prescribe the optimal dosage and duration.

SUMMARY

Proton pump inhibitor treatment should be dose-appropriate and for a limited duration. Concerning potential adverse effects, the limitations of retrospective cohort studies must be taken into consideration when reviewing the evidence.

Esophageal and Gastric Motility Disorders in the Elderly

The elderly are particularly prone to developing upper gastrointestinal disturbances. Changes are due to the aging process, diabetes, cardiovascular risk factors, and neurologic issues. Medications used to treat these underlying conditions can cause gastrointestinal symptoms. Dysphagia is common and can be oropharyngeal and/or esophageal. Gastroparesis is due to either medications such opiates, or due to neurologic sequala of diabetes, cerebrovascular accidents, or neurologic diseases such as Parkinson's disease. Given limitations in many commonly used prokinetics with a wide range of side effect profiles including neurologic and cardiac, the focus of treatment should be on symptom management with dietary changes.

Proton pump inhibitors do not increase the risk of dementia: a systematic review and meta-analysis of prospective studies

Published studies have reported variable results on the association between duration of proton pump inhibitor (PPI) use and the risk of dementia. An extensive literature search was performed in PubMed, Embase, Google Scholar, and Cochrane for studies examining the risk of cognitive decline and dementia among PPI users versus non-PPI users in prospective studies. Retrospective database linkage studies, case reports, case series, editorials, uncontrolled cohort studies, cross-sectional studies, and review articles were excluded. Primary outcome was pooled hazard rate (HR) of any dementia among PPI users compared with non-PPI users. Secondary outcomes were pooled HR of Alzheimer's dementia (AD) and risk with long-term PPI follow-up (more than 5 years) studies. Meta-analysis outcomes, heterogeneity (I2), and meta-regression (for the effect of covariates) were derived by statistical software R and Open meta-analyst. A total of six studies (one RCT and five prospective) with 308249 subjects, average age of 75.8 ± 5.2 years, and follow-up of 5 (range 1.5-11) years were included in the analysis. Pooled HR of any dementia was 1.16 (n = 6, 95% confidence interval (CI) = 0.86-1.47). Results remained unchanged when only studies with long-term PPI use (more than 5 years) were analyzed (n = 4, pooled HR 1.10, 95% CI 0.66-1.53). Finally, the pooled HR for AD was 1.06 (n = 3, 95% CI 0.70-1.41). There was substantial heterogeneity among inclusion studies (I2 = 93%). Meta-regression did not demonstrate a significant role of age at study start (P = 0.1) or duration of PPI use (P = 0.62) to incident dementia. The results of this systematic review and meta-analysis do not show a significant relationship between PPI use and dementia in prospective studies with at least a 5-year follow-up.

GERD for the nongastroenterologist: successful evaluation, management, and lifestyle-based symptom control

Gastroesophageal reflux disease (GERD) is a complex disorder. Symptoms of heartburn can help find the disorder of GERD. pH testing is the mainstay of evaluation of symptoms, including 24-h and longer pH studies to detect pathologic acid exposure. The use of proton pump inhibitor (PPI) therapy for approved indications is helpful for both symptomatic relief and esophagitis healing in the majority of patients with abnormal acid exposure. PPI medications are safe in short- or long-term use. It is recommended not to maintain cirrhotic patients on PPI therapy without a meaningful indication. Dietary adjustment can provide benefit to some patients, but the data are mixed on how much benefit has been demonstrated from specific food avoidance. Reduction in weight improves reflux. Obesity has measurable effects on the esophageal acid exposure but fewer effects on the motility of the esophagus itself. Controlling weight and changing lifestyle can be helpful for improving GERD symptoms. For some patients in whom either the control of reflux with medications and lifestyle change is not sufficient or a hernia is contributing to symptom generation, surgical and endosurgical interventions can be considered to help manage reflux after a thorough workup with pH testing and manometry.

Potential proton pump inhibitor-related adverse effects

Proton pump inhibitors (PPIs) are one of the most common medications taken by patients worldwide. PPIs are used to treat acid-related disorders, including gastroesophageal reflux disease, peptic ulcer disease, Helicobacter pylori infection, and nonsteroidal anti-inflammatory drug/stress ulceration. For some of these diseases, long-term treatment is necessary. With such prolonged use, concern and investigation into potential adverse effects has increased. In addition, data are available regarding potential anticancer effects of PPIs, especially regarding solid tumors. The aim of this review is to assess the literature on PPIs with regard to common concerns, such as drug-drug interactions, the intestinal microbiome, dementia and central nervous system disease, and osteoporosis, as well as to highlight potential negative and positive impacts of the drug in cancer.

Statewide Analysis of Peptic Ulcer Disease: As Hospitalizations Decrease, Procedural Volume Remains Steady

Hospitalizations for peptic ulcer disease (PUD) have decreased since the advent of specific medical therapy in the 1980s. The authors’ clinical experience at a tertiary center, however, has been that procedures to treat PUD complications have not declined. This study tested the hypothesis that despite decreases in PUD hospitalizations, the volume of procedures for PUD complications has remained consistent. The study population included all inpatient encounters in the state of Maryland from 2009 to 2014 with a primary ICD-9 diagnosis code for PUD. Data on annual patient volume, demographics, anatomic location, procedures, complications, and outcomes were collected, and PUD prevalence rates were calculated. The study population consisted of the state's entire population, not a sample; statistical analysis was not applied. Hospitalizations for PUD declined from 2,502 in 2009 to 2,101 in 2014, whereas the percentage of hospitalizations with procedures increased from 27.1 to 31.5 per cent. Endoscopy was performed in 19.8 per cent of hospitalizations, operation in 9.4 per cent, and angiography in 1.3 per cent. Of 13,974 inpatient encounters, 30 per cent had at least one inhospital complication. Overall inpatient mortality was 2.2 per cent. PUD hospitalizations are declining in Maryland, mirroring national trends. A subset of patients continue to need urgent procedures for PUD complications, including nearly 10 per cent needing operation. Inpatient mortality among patients admitted for PUD was 2.2 per cent, congruent with other studies. Despite the efficacy of modern medical therapy, these data underscore the importance of teaching surgical residents the cognitive and operative skills necessary to manage PUD complications.

No Association Linking Short-Term Proton Pump Inhibitor Use to Dementia: Systematic Review and Meta-analysis of Observational Studies

INTRODUCTION

Long-term use of proton pump inhibitors (PPIs) has been associated with a wide variety of potentially serious adverse effects including a possible increased risk of dementia. Studies evaluating this association have reached divergent conclusions. We aimed to evaluate this proposed association further and to assess the quality of the evidence in its support.

METHODS

We searched MEDLINE, EMBASE, ISI Web of Science, and Cochrane databases for studies examining a link between PPI use and dementia, up to February 2019. Studies reporting summary results as hazard ratio (HR) or odds ratio (OR) were pooled using the DerSimonian and Laird random-effects model for meta-analyses. Methodological quality of individual observational studies was assessed using the Newcastle-Ottawa scale and the overall quality of evidence rated as per the GRADE approach.

RESULTS

We identified and included 11 observational studies comprising 642,949 subjects; 64% were women. Most studies were short-term ranging from 5 to 10 years. There were 158,954 PPI users and 483,995 nonusers. For studies summarizing data as adjusted HR, pooled HR for all causes of dementia was 1.10 (0.88-1.37); for Alzheimer dementia only, it was 1.06 (0.72-1.55). For studies summarizing data as adjusted OR, pooled OR for all causes of dementia was 1.03 (0.84-1.25) and for Alzheimer dementia only 0.96 (0.82-1.11). Per Newcastle-Ottawa scale assessment, 10 studies were of high quality and 1 was of moderate quality. By applying GRADE methodology, quality of evidence for both outcomes was very low.

DISCUSSION

We found no evidence to support the proposed association between PPI use and an increased risk of dementia. PPI use among patients who have a valid indication for it, should not be curtailed because of concerns about dementia risk.

Proton Pump Inhibitors: The Good, Bad, and Ugly

Proton pump inhibitors (PPIs) continue to be the medication of choice for treatment of acid-related disease, with few if any overt side effects seen with daily use. They are often prescribed empirically, often in high doses and with many patients being treated with multiple PPIs without an objective diagnosis. Therefore, they are believed to be overprescribed and used without indication. In this article we discuss the appropriate clinical indications for PPIs, review in detail the major associated adverse events, and put in perspective key issues in balancing benefits and risk of this exceptional (and safe) class of drug.

Proton Pump Inhibitors in the Elderly, Balancing Risk and Benefit: an Age-Old Problem

PURPOSE OF REVIEW

Proton pump inhibitors (PPIs) are one of the most prescribed drugs in the developed world and elderly patients are particularly likely to be prescribed acid suppression. There have been reports of many diseases being associated with PPI therapy and the elderly would be particular at risk of any harms these drugs may cause. This review therefore reviews the evidence of the risks and benefits of these drugs.

RECENT FINDINGS

PPIs are very effective at treating acid-related disorders. Recent randomized trials have suggested that the associations between PPI and various diseases are likely to be related to bias and residual confounding and these drugs appear to be safe apart from a possible increase risk of enteric infections. PPIs should be used at the lowest dose and for the shortest duration possible. They are still relatively safe drugs but should only be prescribed for proven indications.

Beyond uncertainty: Negative findings for the association between the use of proton pump inhibitors and risk of dementia

OBJECTIVES

We investigated the risk of dementia associated with the use of proton pump inhibitors (PPIs) as compared with the use of histamine-2 receptor antagonist (H2RA).

METHODS

We conducted retrospective propensity score-matched cohort study using the National Health Insurance Service-National Sample Cohort. Subjects were defined as the patients newly prescribed with PPI or H2RA between 2003 and 2013 without prior prescriptions of PPI/H2RA or diagnosis of dementia from their history within the past 1 year. We followed up participants until dementia occurrence, death, or the end of the study, whichever occurred first, with an intention-to-treat approach. A 1-year lag time between exposure and outcome measure was used to reduce protopathic bias. The incidence rate per 1000 person-years was estimated. The incidence rate of PPI was compared with that of H2RA, defined as incidence rate ratio (IRR), calculated with a 95% confidence interval. To control for potential confounds, propensity score matching at a 1:1 ratio was conducted, and the crude IRR was adjusted by risk factors.

RESULTS

Our propensity score-matched cohort included 87 562 patients on PPIs and 87 562 patients on H2RAs. The IRR was 1.01 (95% confidence interval 0.96-1.06) with 1-year lag time. IRR showed the decreased trend as the longer lag time. Also, no treatment duration or dose-response relationship was observed.

CONCLUSIONS

Our finding demonstrated that PPIs did not associate with dementia more strongly than did H2RA. On this basis, we suggest that the previously reported risk for dementia associated with PPI may have been overestimated.

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.

Drug interactions with dementia-related pathophysiological pathways worsen or prevent dementia

Many risk factors are known to induce or precipitate dementia. Drugs acting via different mechanisms can modulate cognitive performance and exert either beneficial or deleterious effects on cognition through functional or neuropathological mechanisms. This review discusses the association between several classes of drugs and cognitive impairment and dementia risk. These drugs can be divided into drugs targeting CNS disorders (e.g., anticholinergic drugs, antiepileptics, antipsychotics, benzodiazepines, and opioids) and drugs targeting non‐CNS disorders (e.g., antidiabetics, antihypertensives, proton pump inhibitors, and statins). Furthermore, we sought to highlight the pharmacological mechanisms underlying their possible detrimental or beneficial effects on cognition. Anticholinergic and antiepileptic drugs were excluded from this review because their effects on cognition are well known. Studies investigating benzodiazepines have revealed an increased risk of dementia. Conclusions on dementia risk or cognitive impairment regarding opioids and antipsychotic drugs are difficult to draw. These different classes appear to impair cognition not by a single clear mechanism of action specific to each class but by several relatively interdependent and interconnected mechanisms (e.g., impaired neurotransmission, neuroinflammation, neuronal death, oxidative stress, or interactions with dementia‐related pathways). The dementia risk initially associated with the use of proton pump inhibitors might have been overestimated. In contrast, statins, antihypertensive medications, and antidiabetics could potentially decrease the risk of dementia and cognitive impairment by acting in ways opposite to the mechanisms cited above.

Linked Articles

This article is part of a themed section on Therapeutics for Dementia and Alzheimer's Disease: New Directions for Precision Medicine. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v176.18/issuetoc

Adverse effects of proton pump inhibitors: fact or fake news?

PURPOSE OF REVIEW

The present review summarizes the past year's literature, both clinical and basic science, regarding potential adverse effects of proton pump inhibitors.

RECENT FINDINGS

Proton pump inhibitors are amongst the most widely prescribed and overprescribed medications worldwide. Although generally considered well tolerated, epidemiologic studies mining large databases have reported a panoply of purported serious adverse effects associated with proton pump inhibitors, including chronic kidney disease, cognitive decline, myocardial infarction, stroke, bone fracture and even death. It should be noted that the quality of the evidence underlying these associations is very low and these studies, by design, cannot ascribe cause and effect. Nonetheless, these associations have been sensationalized in the media and misinterpreted by patients and providers. Unintended consequences of the fake news are that patients are not being prescribed and/or taking clinical guideline-recommended proton pump inhibitors to prevent and treat complications from gastroesophageal reflux disease and upper gastrointestinal bleeding precipitated by NSAIDs and dual antiplatelet therapies. In addition, physicians, who already have limited time to interact with their patients, are spending an inordinate amount of additional time placing these findings into proper perspective and reassuring their patients when initiating treatment as well as on every follow-up visit.

SUMMARY

Most of the recent highly publicized serious adverse effects ascribed to proton pump inhibitors are not based on demonstrable evidence. Nevertheless, when proton pump inhibitors are prescribed long-term, they should be used at the lowest effective dose and the need for their use periodically reassessed.

Parkinson's Disease and Current Treatments for Its Gastrointestinal Neurogastromotility Effects

PURPOSE OF REVIEW

Gastrointestinal disturbances are seen in nearly all patients with Parkinson's disease and lead to impaired quality of life, affect drug pharmacodynamics, and potentially worsen patient's existing motor fluctuations, leading to further disability. Recent evidence links abnormal accumulations of α-synuclein aggregates in the periphery (gut) as seen in the cortex which causes dysfunctions impacting every level of the gastrointestinal tract from the esophagus, to the stomach, small bowel, colon, and rectum and can even predate the onset of the central neurologic disorder itself. Many treatments exist for the clinical phenotypes that result from the autonomic dysfunction and neuropathy involved in this neurodegenerative disorder. The treatments for the gut dysfunction seen in Parkinson's disease (PD) depend on the specific area of the gastrointestinal tract affected. For dysphagia, behavioral therapies with speech pathology, neuromuscular electrical stimulation, or botulinum toxin injection may be helpful. For gastroparesis, domperidone may serve as an antiemetic while also blunting the hypotensive potential of Levodopa while new treatments such as ghrelin agonists may prove beneficial to help appetite, satiety, gastric emptying in those with constipation, and even improve constipation. Antibiotics such as rifaximin with poor systemic absorption may be used to treat small bacterial overgrowth also found in those with PD while the benefits of probiotics is yet to be determined. Finally, constipation in PD can be a reflection of pelvic floor dyssynergia, slow transit constipation, or both, thus treatments targeting the specific anorectal dysfunction is necessary for better outcomes.