Dementia, cognitive impairment and proton pump inhibitor therapy: A systematic review

Neuropsychological assessment after long-term omeprazole treatment

Recent studies suggest that Omeprazole, a widely used treatment for gastric acid-related disorders, may have a significant effect on human cognition. However, there is no consensus on the matter. Though some studies suggest the drug is associated with an increased risk of cognitive decline, memory impairment, and dementia, this issue has not been sufficiently studied. Therefore, the goal of this study was to investigate the cognitive impairments associated with long-term Omeprazole treatment, with a focus on memory, attention, and executive functions. Additionally, we sought to verify whether the duration of treatment was associated with the magnitude of the associated cognitive impairments. The sample consisted of 30 participants of both genders treated with Omeprazole (experimental group) and 30 participants who did not use the drug (control group). The cognitive assessment battery: Verbal Fluency, Rey Auditory-Verbal Learning, Attention Assessment Battery, Five Digit Test, Hayling Test, and NEUPSILIN Subtest. The groups were compared using Student's T-tests, and the association between treatment duration and cognitive performance was examined using Pearson's coefficients. The results showed significant group differences in verbal fluency, short-term episodic memory, selective attention, and executive functions. The duration of Omeprazole treatment was also positively associated with the magnitude of cognitive impairment.

Signal of dementia with proton pump inhibitor after minimizing competition bias: an updated disproportionality analysis

OBJECTIVE

The association between proton pump inhibitor (PPI) and dementia was controversial. The aim of the current study was to perform an updated pharmacovigilance analysis of the association between dementia event and PPI treatment after minimizing competition bias.

METHODS

We gathered cases reported with PPI treatment based on the United States Food and Drug Administration Adverse Event Reporting System database from 2004 to 2023. We employed disproportionality algorithms, including reporting odds ratio (ROR) and the information component (IC), to detect the association between dementia event and PPI. We investigated the affection of event competition bias on the current disproportionality signal detection.

RESULTS

We finally included a total of 776,191 PPI cases, and 1813 cases in the dementia group. Analyzing primary suspect PPIs, we detected a significant association between dementia and PPI (ROR = 1.38, 95%CI 1.22 to 1.56; IC = 0.46, 95%CI 0.04 to 0.86). After excluding the PPI case with renal injury events, the strength of the dementia signal increased. Omeprazole (589 cases), pantoprazole (514 cases), and esomeprazole (386 cases) were the top three PPI reported with dementia events.

CONCLUSION

The current pharmacovigilance study identified a significant association between dementia and PPIs, except vonoprazan and tegoprazan, especially taking competition bias into account. Further high-quality prospective study still needed.

Long-Term Proton Pump Inhibitor-Acid Suppressive Treatment Can Cause Vitamin B12 Deficiency in Zollinger-Ellison Syndrome (ZES) Patients

Whether the long-term treatment of patients with proton pump inhibitors (PPIs) with different diseases [GERD, Zollinger-Ellison syndrome (ZES), etc.] can result in vitamin B12 (VB12) deficiency is controversial. In this study, in 175 patients undergoing long-term ZES treatment with anti-acid therapies, drug-induced control acid secretory rates were correlated with the presence/absence of VB12 deficiency, determined by assessing serum VB12 levels, measurements of VB12 body stores (blood methylmalonic acid (MMA) and total homocysteine[tHYC]), and other features of ZES. After a mean of 10.2 yrs. of any acid treatment (5.6 yrs. with PPIs), 21% had VB12 deficiency with significantly lower serum and body VB12 levels (p < 0.0001). The presence of VB12 deficiency did not correlate with any feature of ZES but was associated with a 12-fold lower acid control rate, a 2-fold higher acid control pH (6.4 vs. 3.7), and acid control secretory rates below those required for the activation of pepsin (pH > 3.5). Over a 5-yr period, the patients with VB12 deficiency had a higher rate of achlorhydria (73% vs. 24%) and a lower rate of normal acid secretion (0% vs. 49%). In conclusion, in ZES patients, chronic long-term PPI treatment results in marked acid hyposecretion, resulting in decreased serum VB12 levels and decreased VB12-body stores, which can result in VB12 deficiency.

Inappropriate Use of Proton Pump Inhibitor Among Elderly Patients in British Columbia: What are the Long-term Adverse Events?

BACKGROUND

Proton pump inhibitors (PPIs) are one of the most used classes of drugs. For most indications, PPIs are only recommended up to 8 weeks duration. However, PPI use continues to expand. Regular and prolonged use of PPIs should be avoided because of the risk of adverse events.

OBJECTIVES

The main objective of this study was to (1) investigate the extent of PPI usage in people aged 65 or older in the province of British Columbia (BC), Canada, (2) provide an overview of the harms associated with the long-term use of PPIs.

METHODS

We examined utilization trends of the PPIs in BC since the year 2009 using PharmaNet, BC's medication dispensing database where the information is accessible to community pharmacists. We performed a comprehensive literature search for relevant reviews reporting harms associated with long-term use of PPIs. A search was conducted from January 2014 to June 2022.

RESULTS

Between 2000 and 2018 BC's population grew by 20%, but the use of PPIs escalated to 257%. Of these older British Columbians, 62% had a cumulative exposure exceeding 2 years and 42% exceeded 5 years. This is alarming because the recommended treatment duration is 4-12 weeks for common indications including reflux esophagitis, and duodenal and gastric ulcers. Only 13.5% were dispensed PPIs for 90 days or less. Patients on long-term PPI therapy should be reassessed. Adverse events of PPI use are common among older adults. We identified over 217 systematic reviews published during the last 8 years of specific harms associated with long-term daily usage of PPIs. These harms include increased risks of death, cardiovascular disease, acute renal injury, chronic kidney disease, dementia, fractures, hypomagnesemia, iron deficiency, vitamin B12 deficiency, enteric infection (including C. difficile), pneumonia, and neoplasia (gastric cancer, carcinoids, and colon cancer), and drug interactions.

CONCLUSION

This study revealed a high prevalence of PPI use among elderly populations in BC, Canada. The overutilization of PPIs is often a result of failure to re-evaluate the need for continuation of therapy. Published studies identified signals of serious harm from long-term PPI exposure. Healthcare providers with patients can reverse the relentless expansion of long-term PPI exposure by discussing the expected benefits and potential harms.

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.

Gastroesophageal reflux disease management and chronic use of proton pump inhibitors

ABSTRACT

Proton pump inhibitors (PPIs) are one of the most commonly prescribed drugs worldwide and have changed the treatment of gastroesophageal reflux disease (GERD). However, these drugs have been associated with several potentially serious adverse reactions if used chronically. Guidelines from the American College of Gastroenterology in 2021 and the American Gastroenterological Association's 2022 clinical practice updates reflect the latest recommendations. This article reviews the management and treatment of GERD and the adverse reactions to long-term PPI use.

The clinical effect of benesco™ on reflux symptoms: A double-blind randomized placebo-controlled trial

BACKGROUND

Gastroesophageal reflux disease (GERD) is one of the most prevalent gastrointestinal diseases in the western world. Lifestyle modifications and proton pump inhibitors (PPIs) form the basis of the management of GERD. A subset of patients seeks for (natural) alternative therapies besides PPIs. benesco™ is an over-the-counter nutrition based on quercetin which has a presumed positive effect on esophageal barrier function. Therefore we aim to assess the effect of benesco™ on reflux symptoms.

METHODS

We performed a double-blind randomized placebo-controlled trial in participants with reflux symptoms. Participants were assigned randomly (1:1) to receive 6 weeks of benesco™ (three times daily one lozenge containing 200 mg of quercetin) or placebo. The primary outcome was treatment success (≥50% reduction in Reflux Disease Questionnaire Score). Secondary outcomes included GERD-related quality of life, reflux-free days and nights, and participant-reported treatment success.

KEY RESULTS

One hundred participants were randomized. Treatment success was seen in 18 (39%) of 46 participants in the intervention group versus 21 (47%) of 45 in the placebo group (p = 0.468). In the intervention group 10 (1-21) reflux-free days were reported compared to 10 (2-25) in the placebo group (p = 0.673). In addition, 38 (34-41) versus 39 (35-42) reflux-free nights were reported (p = 0.409).

CONCLUSIONS & INFERENCES

In our trial benesco™ showed no significant benefit over placebo at group level.

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.

Proton pump inhibitor-induced gut dysbiosis and immunomodulation: current knowledge and potential restoration by probiotics

Proton pump inhibitors (PPIs) are the most commonly prescribed drugs for the treatment of non-erosive reflux disease (NERD), ulcers associated with non-steroidal anti-inflammatory drugs (NSAIDs), esophagitis, peptic ulcer disease (PUD), Zollinger-Ellison syndrome (ZES), gastroesophageal reflux disease (GERD), non-ulcer dyspepsia, and Helicobacter pylori eradication therapy. The drugs have the effect of inhibiting acid production in the stomach. According to research, PPIs can affect the composition of gut microbiota and modulate the immune response. Recently, there has been a problem with the over-prescription of such drugs. Although PPIs do not have many side effects, their long-term use can contribute to small intestinal bacterial overgrowth (SIBO) or C. difficile and other intestinal infections. Probiotic supplementation during PPIs therapy may provide some hope in the reduction of emerging therapy side effects. This review aims to present the most important effects of long-term PPI use and provides critical insights into the role of probiotic intervention in PPI therapy.

Updated Insights on Cardiac and Vascular Risks of Proton Pump Inhibitors: A Real-World Pharmacovigilance Study

Background

Proton pump inhibitors (PPIs) are among the most widely prescribed medications in clinical practice. However, there are also concerns about the potential risks of long-term PPI use. The present study aimed to examine the safety of PPIs and summarize their potential cardiac and vascular risks in a real-world setting.

Methods

This pharmacovigilance study extracted records between January 2015 and December 2019 from the FDA Adverse Event Reporting System (FAERS) database. The association of seven PPI medications with cardiac and vascular events (CVEs) were evaluated. Two established pharmacovigilance methods, reporting odds ratio (ROR) and information components (IC) based statistical shrinkage, were used to measure disproportionality.

Results

In total 62,140 CVE records associated with PPI use were investigated. Women showed a higher proportion (54.37%) of PPI-associated CVEs. The median time from PPI initiation to CVE onset was 97 [interquartile range (IQR): 8–491] days, with the shortest median time of 42 days (IQR: 2–277 days) for esomeprazole, and the longest time of 389 days (IQR: 0–525 days) for dexlansoprazole. Although PPIs were not associated with elevated CVE risks compared those of the whole database (IC₀₂₅/ROR₀₂₅ = −0.39/0.74), various signals emerged. Despite some similarities exist between the PPIs, their cardiac and vascular safety profiles varied significantly. Pantoprazole showed the broadest spectrum of signals, from thrombotic thrombocytopenic purpura (IC₀₂₅/ROR₀₂₅ = 0.01/1.08) to renal haemangioma (IC₀₂₅/ROR₀₂₅ = 3.14/9.58). Esomeprazole showed the second-broadest spectrum of toxicities, ranging from duodenal ulcer hemorrhage (IC₀₂₅/ROR₀₂₅ = 0.07/1.28) to hypertensive nephropathy (IC₀₂₅/ROR₀₂₅ = 4.09/18.72). Vascular signals were more dominant than cardiac signals, suggesting that vascular function was more heavily affected. Hypertensive nephropathy, renal haemangioma, renal artery stenosis, and renal infarct had strong signals across most PPI regimens and merited further attention.

Conclusions

PPIs may inflict various CVEs, particularly those involving the vascular system, on the users. Given the wide range of onset times and different toxicity profiles for various PPI medications, they should be prescribed with caution.

ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) continues to be among the most common diseases seen by gastroenterologists, surgeons, and primary care physicians. Our understanding of the varied presentations of GERD, enhancements in diagnostic testing, and approach to patient management have evolved. During this time, scrutiny of proton pump inhibitors (PPIs) has increased considerably. Although PPIs remain the medical treatment of choice for GERD, multiple publications have raised questions about adverse events, raising doubts about the safety of long-term use and increasing concern about overprescribing of PPIs. New data regarding the potential for surgical and endoscopic interventions have emerged. In this new document, we provide updated, evidence-based recommendations and practical guidance for the evaluation and management of GERD, including pharmacologic, lifestyle, surgical, and endoscopic management. The Grading of Recommendations, Assessment, Development, and Evaluation system was used to evaluate the evidence and the strength of recommendations. Key concepts and suggestions that as of this writing do not have sufficient evidence to grade are also provided.

Proton pump inhibitors and increased reporting odds of renal neoplasms: FAERS-based adverse event data mining and analysis

BACKGROUND

Long-term use of proton pump inhibitors (PPIs) is associated with some safety issues. In this study, data mining was carried out to discover the potential association between renal neoplasms and PPIs.

RESEARCH DESIGN AND METHODS

Neoplasms signals of PPIs were detected in the Food and Drug Administration Adverse Event Reporting System from 2014 to 2020 by examining the reporting odds ratio. Adjusted odds ratios were analyzed using logistic regression.

RESULTS

Signals were detected with respect to renal hemangioma, acquired or unspecified cystic kidney disease, and papillary and unspecified renal cell carcinoma, of which intervals between adverse effects onset and medication were 7.00 (3.33, 15.67) years, 5.00 (1.70, 10.25) years, and 7.00 (4.72, 12.25) years, respectively. The lansoprazole had the strongest signal. Adjusted odds ratios for PPIs associated with renal cell carcinoma in cases with or without acquired cystic kidney disease or chronic kidney disease were 1.67 [95% confidence interval (CI) 1.46-1.91] and 1.62 (95% CI 1.41-1.87).

CONCLUSIONS

Exposure to PPIs was related to the raised risk of renal neoplasms. Careful consideration should be given to the possibility of an increased risk when PPIs are administered.

The Janus-like Association between Proton Pump Inhibitors and Dementia

Early pharmacoepidemiological studies suggested that Proton Pump Inhibitors (PPIs) might increase the risk of Alzheimer’s Disease (AD) and non-AD related dementias. These findings were supported by preclinical studies, specifically stressing the proamyloidogenic and indirect anticholinergic effects of PPIs. However, further large-scale pharmacoepidemiological studies showed inconsistent results on the association between PPIs and dementia. Pharmacodynamically, these findings might be related to the LXR/RXR-mediated amyloid clearance effect and anti-inflammatory action of PPIs. Further aspects that influence PPI effects on AD are related to patient-specific pharmacokinetic and pharmacogenomic characteristics. In conclusion, a personalized (individualized) medicinal approach is necessary to model and predict the potential harmful or beneficial effects of PPIs in AD and non-AD-related dementias in the future.

Proton pump inhibitors long term use-trends and patterns over 15 years of a large health maintenance organization

BACKGROUND

Proton pump inhibitors (PPI) are used for a variety of indications. Despite reported associations with undesirable effects, their long-term use is on the rise, while appropriate indications, dose, and treatment duration may deviate from guideline recommendations.

OBJECTIVES

Primary to examine the annual patterns of PPI use. Secondary- to assess indications for initiating PPI treatment, long-term use, and factors associated with long-term use in a large Israeli health maintenance organization.

METHODS

A historical cohort study of 528 420 eligible PPI users during 2000-2015, analyzed PPI use using defined daily doses and the proportion of patients covered method. Data on indications for treatment initiation, clinical and socio-demographic parameters were captured as well. A multivariable logistic-regression model was used to identify factors associated with long-term use of PPI.

RESULTS

The annual incidence rates of patients initiating PPI treatment were relatively constant, ranging between 2.4% and 3.1% of the adult population, with a monotonic increase in annual consumption and prevalence (reaching 12.7% in 2015). Reflux, functional symptoms, and Helicobacter pylori eradication were the most common indications for initiating PPI therapy. However, 27% of patients had no recorded indication for treatment. Fifteen percent of patients used PPI for over 6 months, especially in older age groups.

CONCLUSIONS

Utilization of PPI increases steadily, mainly due to chronic use. Prolonged consumption is associated with specific clinical indications and older age. Health organizations should encourage awareness of appropriate use among physicians, specifically in the elderly, patients with reflux, and those with functional disorders.

Abrupt-onset, profound erectile dysfunction in a healthy young man after initiating over-the-counter omeprazole: a case report

Background

Proton pump inhibitors are frequently used (and often overused) medications with adverse effects including vitamin B12 deficiency, Clostridium difficile colitis, and increased risk of chronic kidney disease. Erectile dysfunction is largely unrecognized as an adverse effect of proton pump inhibitors despite increasing evidence that proton pump inhibitors may contribute to impaired nitric oxide generation and endothelial dysfunction.

Case presentation

A 38-year-old Caucasian man with mild hypertension and no other significant medical history developed profound erectile dysfunction within 2 days of initiating over-the-counter omeprazole therapy, with erectile function rapidly normalizing following discontinuation of the drug. At the time of the episode, the patient was on a stable dose of lisinopril and was taking no other medications or supplements. In the 2 years following the episode, the patient has had no further erectile difficulties.

Conclusion

Further study of erectile dysfunction as an adverse effect of proton pump inhibitors is needed. In the meantime, proton pump inhibitors should be considered as a potential cause of erectile dysfunction in healthy young patients and as a cause or contributor to erectile dysfunction in older patients in whom erectile dysfunction is often attributed to age or comorbidities.

The inappropriate use of proton pump inhibitors and its associated factors among community-dwelling older adults

Objectives

Little is known about the inappropriate use of proton pump inhibitors (PPIs) and how mild cognitive impairment (MCI) and high comorbid burden relate to the inappropriate prescribing of PPIs. Therefore, the current study aimed to examine these associations among community-dwelling older adults in Jordan.

Method

This cross-sectional study was conducted on 215 community-dwelling older adults from three local healthcare centers located in Irbid, Jordan. Data about PPI use, including the name of medication, dose, frequency, duration, and indication, were collected retrospectively from a review of the participating older adults’ medication cards for November and December 2019. The collected data were evaluated based on the Food and Drug Administration (FDA) guidelines. MCI was measured using the Arabic version of the Montreal Cognitive Assessment, and comorbid burden was measured using the Cumulative Illness Rating Scale for Geriatrics.

Results

Forty-seven percent of the participants were found to have taken a PPI, with 68 % having taken one for a longer period than recommended by the FDA. Older adults with MCI or high comorbid burden were found to be more susceptible than other older adults to the long-term use of PPIs. The logistic regression revealed that MCI is a statistically significant predictor of inappropriate PPI use (p < 0.001).

Conclusion

Inappropriate PPI use is common among community-dwelling older adults in Jordan, with a significantly higher prevalence of inappropriate PPI use in people with MCI than in people with normal cognitive abilities. Future intervention studies are highly recommended to encourage optimal prescribing of PPIs for community-dwelling older adults.

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.

Electrophilic and Drug-Induced Stimulation of NOTCH3 N-terminal Fragment Oligomerization in Cerebrovascular Pathology

Small vessel disease is a prevalent age-related condition linked to increased risk of dementia and stroke. We investigate the most commonly inherited form, CADASIL, caused by cysteine-involving mutations in NOTCH3. Recent studies highlight accumulation of NOTCH3 N-terminal fragmentation product (NTF) in disease. In vitro, NTF is capable of both spontaneous and catecholamine-enhanced cysteine-mediated oligomerization. Despite well-characterized genetic influence on CADASIL, environmental effects, including medication usage, on disease remain unclear. We studied effects of assorted electrophilic compounds and drugs on NTF oligomerization by SDS-PAGE and dynamic light scattering. We then examined direct proton pump inhibitor-NTF binding with antibodies designed against proton pump inhibitor-labeled proteins and mass spectrometry. Finally, we used monoclonal NTF antibodies with Proximity Ligation Assay to identify NTF oligomers in 3 CADASIL and 2 age-matched control brains. We identified enhancement of NTF oligomerization by two electrophilic cysteine-modifying compounds, N-ethylmaleimide and iodoacetamide, and an electrophilic compound capable of oxidizing cysteines, ferric chloride. Electrophilic clinical drugs (fenoldopam, omeprazole, tenatoprazole, lansoprazole, and rabeprazole) also promoted oligomerization, and we identified direct omeprazole-NTF and tenatoprazole-NTF complexes. Additionally, we provide novel evidence of NTF multimers in human CADASIL brains. A broad array of electrophilic chemicals, including clinically relevant drugs, influences oligomerization of a pathological CADASIL protein, providing mechanistic insight into disease protein oligomerization. We posit that environmental influences, which may include usage of electrophilic drugs, may affect CADASIL presentations.

The effects of proton pump inhibitors on neuropsychological functioning

OBJECTIVE

The current study investigated the effects of proton pump inhibitor use and apolipoprotein ε4 carrier status on changes in neuropsychological functioning in healthy adults with familial risk factors for dementia.

METHODS

As part of the Wisconsin Registry for Alzheimer's Prevention study, 1,573 subjects were administered questionnaires on their medical history, gave blood samples, and were administered neuropsychological assessments during four visits over a 10-15 year period. Linear mixed models assessed if non-users, subjects who stopped, started, or consistently used proton pump inhibitors differed in changes in working memory, verbal memory, psychomotor speed, and cognitive flexibility.

RESULTS

The models did not yield significant main effects for proton pump inhibitor use or interaction effects between proton pump inhibitor use and apolipoprotein ε4 carrier status on a decline in memory or processing speed. An interaction effect suggested stopping a proton pump inhibitor may be protective against declines in cognitive flexibility among non-carriers.

CONCLUSIONS

Although stopping a proton pump inhibitor use may have mild protective effects on executive functioning for non-apolipoprotein ε4 carriers, proton pump inhibitor use was not associated with memory decline in a sample of subjects with familial risk factors for dementia.

Is there an association between peptic ulcer disease and osteoporosis: a systematic review and cumulative analysis

BACKGROUND

Mounting studies have emerged indicating that patients with peptic ulcer disease (PUD) are at a high risk of developing osteoporosis, but the evidence has not been previously synthesized. The present study aims to examine whether patients with PUD have a significantly higher prevalence of osteoporosis than the healthy normal subjects.

METHODS

Four electronic databases were systematically searched for eligible studies up to February 2020. The association between PUD and osteoporosis was evaluated by calculating the relative risk (RR) with a 95% confidence interval (CI).

RESULTS

Six observational studies were finally included, enrolling a total of 216 122 individuals. Synthetic results from the six included studies providing the number of cases for both sexes demonstrated that PUD was significantly associated with an increased risk of osteoporosis (95% CI, 1.37-1.89; P < 0.001). In line with this finding, the combined effect from the three studies independently reporting the male subjects also yielded to a positive relationship between PUD and osteoporosis (RR = 2.08; 95% CI,1.10-3.93; P = 0.023). However, when restricted to female participants, pooled results indicated that women patients with PUD would not suffer significantly more risk of osteoporosis than the general women population (RR = 1.36; 95% CI, 0.84-2.21, P = 0.212).

CONCLUSIONS

This is the first study for quantifying the positive association between PUD and the risk of osteoporosis by conducting a meta-analysis. In clinical practice, assessment of the bone mineral density and antiosteoporosis treatments are recommended for those potential patients with PUD.

[Updating in prescription of proton pump inhibitors. What to do and what not to do]

INTRODUCTION

Proton pump inhibitors (PPIs) are the most prescribed pharmacological subgroup of the National Health System and their use has been related to possible potentially serious adverse effects.

OBJECTIVE

To review the current indications for treatment with PPIs as well as the data related to their safety, in order to promote their adecuate use.

MATERIAL AND METHODS

A review of the literature focused on the following topics has been carried out: a) molecules and mechanism of action; b) current indications for treatment and adherence to them; c) adverse effects related to its use; d) drug interactions; e) alternatives in deprescription.

RESULTS

The current indications have not changed substantially in recent years and are well established, however, there is a high percentage of inappropriate prescription, mainly in individuals with low or no risk.

CONCLUSIONS

PPIs are safe drugs and generally well tolerated and their benefits are higher than possible adverse effects. Adhering to evidence-based recommendations represents the only rational approach to safe and effective therapy.

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.

Role of nurses in supporting proactive deprescribing

Deprescribing is the term used to describe the discontinuation of medicines. It can be either 'reactive', for example in response to an adverse event or therapeutic failure, or 'proactive', when the prescriber and patient decide to discontinue the medicine because its future benefits no longer outweigh its potential for harm. At present, there is a limited amount of proactive deprescribing activity in primary and secondary care. This article provides the rationale for increasing proactive deprescribing activity, lists the medicines this relates to, identifies the barriers and enablers to its implementation, and describes the potential role of the nurse in this process.

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.

Cognitive problems of breast cancer survivors on proton pump inhibitors

PURPOSE

Proton pump inhibitors (PPIs) are used in cancer patients to manage treatment-related gastrointestinal symptoms and to prevent damage to the gastric mucosal lining during treatment. However, PPI use may contribute to cognitive problems. To compare PPI-users and non-users, breast cancer survivors reported cognitive problems in three studies.

METHODS

In Study 1, breast cancer survivors (N = 209; n = 173 non-users, n = 36 PPI-users; stages 0-IIIC) rated their cognitive function on the Kohli scale prior to cancer treatment, as well as one and two years later. In Study 2, women (N = 200; n = 169 non-users, n = 31 PPI-users, stages 0-IIIa, M = 11 months post-treatment) rated their cognitive function on the Kohli scale and BCPT checklist at three visits over a six-month period. In Study 3, participants (N = 142; n = 121 non-users, n = 21 PPI-users; stages I-IIIa, M = 4 years post-treatment) rated their cognitive function on the Kohli scale, BCPT checklist, and Functional Assessment of Cancer Therapy cognitive scale (FACT-cog).

RESULTS

In Study 1, PPI-users reported more severe concentration problems (p = 0.039) but not memory problems (p = 0.17) than non-users. In Study 2, PPI-users reported more severe concentration problems (p = 0.022) than non-users, but not memory problems or symptoms on the BCPT (ps = 0.11). Study 3's PPI-users reported more severe memory problems (p = 0.002), poorer overall cognitive function (p = 0.006), lower quality of life related to cognitive problems (p = 0.005), greater perceived cognitive impairment (p = 0.013), and poorer cognitive abilities (p = 0.046), but not more severe concentration problems (p = 0.16), compared to non-users.

CONCLUSIONS/IMPLICATIONS

PPI use may impair breast cancer survivors' memory, concentration, and quality of life.

No association between proton pump inhibitor use and risk of dementia: Evidence from a meta-analysis

BACKGROUND AND AIM

A growing body of literature suggests the association between dementia risk and proton pump inhibitor (PPI) use. Therefore, we aimed to investigate the association between PPI use and dementia risk.

METHODS

An extensive literature search was performed in PubMed, Embase, and Cochrane till March 31, 2019. All the studies (cohort and case-control) assessing the association between PPI use and dementia risk were eligible for inclusion. Articles were selected based on the screening of title and abstract, data were extracted, and risk of bias was assessed using Newcastle-Ottawa scale. The primary outcome was pooled risk of dementia among PPI user as compared with non-PPI user. Secondary outcomes include dementia risk based on subgroups. Statistical analysis was performed using review manager software.

RESULTS

Twelve studies (eight cohort and four case-control) were found to be eligible for inclusion. Majority of the studies were of high quality. Dementia was diagnosed based on International Classification of Diseases 9/10 codes in majority of the included studies. PPI use was not associated with the dementia risk, with a pooled relative risk (RR) of 1.05 (95% confidence interval [CI]: 0.96-1.15), P = 0.31. Subgroup analysis based on study design (cohort: P = 0.14; case-control: P = 0.14), sex (RR 1.25 [95% CI: 0.97-1.60], P = 0.08), histamine 2 receptor antagonist blockers (P = 0.93), and Alzheimer's disease (RR 1.00 [95% CI: 0.91-1.09], P = 0.93) revealed no significant association between PPI use and dementia risk.

CONCLUSION

We found no significant association between PPI use and the risk of dementia or Alzheimer's disease.

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.

Successful deprescribing of unnecessary proton pump inhibitors in a primary care clinic

OBJECTIVE

The objective of this study was to determine the rate of successful deprescribing of unnecessary proton pump inhibitors (PPIs) after implementation of a clinical pharmacist- managed program that included detailed tapering instructions, patient education, and follow-up.

SETTING

The setting was a family medicine clinic in St. Paul, MN, in an underserved community.

PRACTICE DESCRIPTION

Eligible patients were taking a long-term PPI for gastroesophageal reflux disease without esophagitis, or without a clear indication. Each morning, the clinical pharmacist generated a report in the electronic medical record that identified patients with appointments who were currently prescribed a PPI. After chart review, the pharmacist determined if patients were candidates for PPI deprescribing. If so, a focused visit with these patients was conducted.

PRACTICE INNOVATION

A unique pharmacist-managed PPI tapering schedule was developed and implemented to deprescribe unnecessary PPI therapy in a family medicine clinic.

EVALUATION

Eligible patients were seen by the pharmacist and initiated on a PPI taper. After 8 weeks, the patients who were initiated on a PPI taper were evaluated to determine if they successfully discontinued the PPI completely, decreased the dose or frequency, or were unsuccessful at tapering the PPI.

RESULTS

Of the patients assessed (N = 126), 60% were excluded, 19% were unable to be seen, and 21% were willing to attempt the taper and discontinue their PPI. Of the 22 patients who initiated PPI deprescribing, 19 (86%) successfully discontinued their PPI completely, 2 (9%) decreased the dose or frequency, and 1 (5%) was unable to decrease or discontinue their PPI. This success rate of PPI discontinuation was higher than that in previous studies in primary care settings (31%-66%).

CONCLUSION

Deprescribing long-term PPI therapy can be successful in a family medicine clinic when implementing a clinical pharmacist-managed program that includes detailed tapering instructions, patient education, and follow-up.

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

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.

A comparative study on the possible protective effect of esomeprazole, spirulina, wheatgrass on indomethacin-induced gastric ulcer in male albino rats

Gastric ulcer is a common problem affecting the gastrointestinal tract. Spirulina and wheatgrass are natural substances that have anti-inflammatory and antioxidant effects. The aim of the Work was to elucidate the possible protective role of spirulina and wheatgrass versus standard treatment esomeprazole on indomethacin-induced gastric ulcer in adult male albino rats. Eighty adult male albino rats were divided into eight groups: group I (the control group), group II that received indomethacin (100 mg/kg orally), group III that received esomeprazole (20 mg/kg orally), group IV that received spirulina (1000 mg/kg orally), group V that received wheatgrass (1000 mg/kg orally), group VI that received indomethacin (100 mg/kg) + esomeprazole (20 mg/kg), group VII that received indomethacin (100 mg/kg) + spirulina (1000 mg/kg) and group VIII that received indomethacin (100 mg/kg) + wheatgrass (1000 mg/kg). Six hours after indomethacin treatment, all rats were anesthetized and their stomachs obtained for measures of gastric acidity, pepsin activity, mucin content, gastrin, ulcer index, total antioxidant capacity (TAC), tumor necrosis factor -α (TNF-α), interleukin-8 (IL8), proapoptotic protein (Bax). Histological (using H&E stain, PAS reaction) and immunohistochemical (using anti Ki67 immunostain) techniques were performed. Western immunoblot analysis for heat shock protein 70 (HSP70) was also done. Moreover, a morphometric study was done for area% of positive immunoreactive cells for Ki67 and optical density and area% of PAS reaction. All performed measurements were followed by statistical analysis. Indomethacin induced loss of normal architecture of gastric mucosa with sloughing of surface epithelium and inflammatory cellular infiltration. It also led to a significant increase in gastric acidity, inflammatory mediators (TNF-α, IL-8), pro-apoptotic protein Bax and a significant decrease in TAC levels and HSP-70 expression. There was also a significant decrease in area% of Ki67 immunoreactivity and area% and optical density of PAS reaction as compared with the control group and other pre-treated rats. These disturbed parameters were associated with increased ulcer index. In pre-treatment groups, the structure of the mucosa was similar to control with marked improvement in the biochemical assay. In conclusion, Spirulina and wheatgrass can partly protect the gastric mucosa against indomethacin-induced damage to a degree similar to that of the classical treatment esomeprazole.

The association between proton pump inhibitor use and the risk of tuberculosis: A case-control study

PURPOSE

Few studies have reported an association between proton pump inhibitor (PPI) use and tuberculosis. Tuberculosis incidence is relatively high in Asian people, and an increase in PPI prescriptions has been reported in South Korea. Thus, we investigated the association between PPI use and tuberculosis development.

METHODS

We conducted a case-control study on 25 672 newly diagnosed tuberculosis patients using the National Health Insurance Service-National Sample Cohort (NHIS-NSC) database (2002-2013). We selected a control group without tuberculosis using 1:1 exact matching based on age, sex, index year, insurance type, and income level. We investigated PPI exposure 2 years prior to the index date and classified the subjects into nonuser, continuous user, recent user, and former user groups. Odds ratios (ORs) and 95% confidence intervals (CIs) for tuberculosis development were calculated using conditional logistic regression.

RESULTS

A total of 51 344 cases and controls were analyzed. Recent PPI use (adjusted odds ratio [aOR], 1.28; 95% CI, 1.18-1.39) and continuous PPI use (aOR, 1.13; 95% CI 1.10-1.28) were significantly associated with tuberculosis development, compared with nonuse of PPIs. An increased tuberculosis incidence was not observed in the former use group compared with the nonuse group (aOR 1.05, 95% CI 0.95-1.17).

CONCLUSIONS

In this case-control study, we found that recent PPI use and continuous PPI use were associated with increased tuberculosis development. Although further investigation is needed, the tuberculosis risk accompanying PPI treatment should be considered.

Proton pump inhibitor use and risk of dementia: Systematic review and meta-analysis

BACKGROUND

Proton pump inhibitors (PPIs) are an established kind of drugs used to the treatment of most acid-related diseases. Some prospective studies have noticed that PPI use was associated with increased dementia risk. However, the results of those studies were inconsistent and controversial. This meta-analysis aims to determine the association of PPI use and risk of dementia among older people.

METHODS

Relevant articles were systematically identified by searching the PubMed, EMBASE, and Cochrane Library databases from inception to February 2018. Cohort studies that reported the risk of dementia or Alzheimer's disease (AD) among PPI users compared with non-PPI users were included. The quality of studies was assessed using the Newcastle-Ottawa Scale (NOS). The publication bias was detected by a funnel plot and Egger test. The meta-analysis will abstract risk estimates including relative risks (RRs), hazard ratios (HRs), and odds ratios (ORs) with a 95% confidence interval (CI) for the associations between PPI use and dementia or Alzheimer's risk. Study-specific results were pooled using a random-effects model.

RESULTS

Six cohort studies were selected finally. The pooled RRs of dementia and AD were 1.23 (95% CI: 0.90-1.67) and 1.01 (95% CI: 0.78-1.32), respectively, compared with those of non-PPI use. The Egger test and funnel plot showed no existence of publication bias. Overall, there was no statistically significant association between PPI use and risk of dementia or AD (P >.05).

CONCLUSIONS

This meta-analysis suggests that there was no statistical association between PPIs use and increased risk of dementia or AD.

PPI Long Term Use: Risk of Neurological Adverse Events?

The purpose of this review study is to reveal a potential threat of one type of such widely used and freely distributed drugs, which are proton pump inhibitors that might be the cause of the onset of both dementia and depression. The authors performed a literature review of available studies on the research topic describing the adverse effect of proton pum inhibitors (PPIs) (omeprazole, esomeprazole, lansoprazole, dexlansoprazole, rabeprazole, pantoprazole, dexrabeprazole, ilaprazole). For a long time, PPIs were considered to be completely safe drug substances for both short and long-term use. In recent years, there have been a few contradictory studis of absolute safety, especially in patients, who have long been using PPIs. At this time when depression and dementia are rising in the population, this is a very worrying fact that needs to be highlighted, and which needs to be carefully studied and evaluated, ideally trying to prevent it. The findings of most research studies described in this review indicate that there is a direct association between the onset of dementia and depression on one side and the long-term use of PPIs on the other.

Proton pump inhibitors and risk of hip fracture: a meta-analysis of observational studies

We performed a meta-analysis of relevant studies to quantify the magnitude of the association between proton pump inhibitors (PPIs) and risk of hip fracture. Patients with PPIs had a greater risk of hip fracture than those without PPI therapy (RR 1.20, 95% CI 1.14-1.28, p < 0.0001). These results could be taken into consideration with caution, and patients should also be concerned about the inappropriate use of PPIs.

INTRODUCTION

Proton pump inhibitors (PPIs) are generally considered as first-line medicine with great safety profile, commonly prescribed for gastroesophageal reflux disease (GERD) and peptic ulcer disease. However, several epidemiological studies documented that long-term use of PPIs may be associated with an increased risk of hip fracture. Although, the optimal magnitude of the hip fracture risk is still undetermined. We, therefore, performed a meta-analysis of relevant studies to quantify the magnitude of the association between PPIs and risk of hip fracture.

METHODS

We collected relevant articles using MEDLINE, EMBASE, Google Scholar, and Web of Science from January 1, 1990, to March 31, 2018. We included only the large (n ≥ 500) observational studies with a follow-up duration of at least one year in which the hip fracture patients were identified by a standard procedure. Two of the authors extracted data from each included study independently according to a standardized protocol.

RESULTS

A total of 24 observational studies with 2,103,800 participants (319,568 hip fracture patients) met all the eligibility criteria. Patients with PPIs had a greater risk of hip fracture than those without PPI therapy (RR 1.20, 95% CI 1.14-1.28, p < 0.0001). An increased association was also observed in both low and medium doses of PPI taken and hip fracture risk (RR 1.17, 95% CI 1.05-1.29, p = 0.002; RR 1.28, 95% CI 1.14-1.44, p < 0.0001), but it appeared to be even greater among the patients with higher dose (RR 1.30, 95% CI 1.20-1.40, p < 0.0001). Moreover, the overall pooled risk ratios were 1.20 (95% CI 1.15-1.25, p < 0.0001) and 1.24 (95% CI 1.10-1.40, p < 0.0001) for the patients with short- and long-term PPI therapy, respectively, compared with PPI non-users.

CONCLUSION

Our results suggest that PPI use is significantly associated with an increased risk of hip fracture development, which is not observed in H2RA exposure. Physicians should, therefore, exercise caution when considering a long-term PPI treatment to their patients who already have an elevated risk of hip fracture. In addition, patients should be concerned about the inappropriate use of PPIs; if necessary, then, they should continue to receive it with a clear indication.

Systematic review with meta-analysis: risk of adverse cardiovascular events with proton pump inhibitors independent of clopidogrel

BACKGROUND

Clopidogrel's anti-platelet effects may be attenuated by a pharmacokinetic interaction with co-prescribed proton pump inhibitors, which inhibit oxidative pathways that convert clopidogrel into its active metabolites. Despite this, the impact of PPIs on cardiovascular risk in the absence of clopidogrel is not well defined.

AIM

To report on a systematic review and meta-analysis of the association between PPIs and cardiovascular risk, independent of clopidogrel.

METHODS

The databases of MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Scopus, Web of Science, and ClinicalTrials.gov were systematically searched in October 2017. The primary outcome was association between PPI monotherapy and any adverse cardiovascular event. The secondary outcome was association between proton pump inhibitor monotherapy and acute myocardial infarction. Studies were excluded if they reported or did not adjust for concomitant anti-platelet therapy or involved participants aged less than 18 years.

RESULTS

A total of 22 studies were included in the systematic review. Data from 16 studies were included in the meta-analysis (involving 447 408 participants). Of these, eight were randomised controlled trials, seven were observational studies and one was a retrospective analysis of a randomised controlled trial. An increased risk of any adverse cardiovascular event with PPI monotherapy was observed using pooled data from observational studies (risk ratio 1.25, 95% CI 1.11-1.42, I² 81%, P < 0.001), but not from randomised controlled trials (risk ratio 0.89, 95% CI 0.34-2.33, I² 0%, P = 0.85).

CONCLUSION

There is no clear evidence of an association between PPI monotherapy and increased cardiovascular risk.

Association between Proton Pump Inhibitor Use and CNS Infection Risk: A Retrospective Cohort Study

This study investigated the incidence of central nervous system (CNS) infection following the use of proton pump inhibitors (PPIs). A retrospective cohort study was conducted in Taiwan by using data from the National Health Insurance Research Database. We identified and enrolled 16,241 patients with CNS infection who used PPIs (PPI users). The patients were individually propensity score matched (1:1) according to age, sex, hypertension, hyperlipidemia, Charlson comorbidity index (CCI), H2 blocker, non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroid, and immunosuppressant use with 16,241 controls (PPI nonusers). A Cox proportional hazards model was used to estimate adjusted hazard ratio (aHR) for CNS infection in the PPI users and nonusers. After adjustment for other confounding factors, the incidence of CNS infection in the PPI users was 2.23-fold higher than that in the PPI nonusers (95% CI = 1.27⁻3.94). In addition, the PPI users exhibited a higher risk of CNS infection than the nonusers in the hypertension and CCI = 1 groups (aHR = 3.80, 95% CI = 1.40⁻10.32; aHR = 2.47, 95% CI = 1.07⁻5.70 in the PPI users and nonusers, respectively). In conclusions, according to these results, we concluded that the incidence of CNS infection was higher in the PPI users than in the nonusers.

Proton Pump Inhibitors and Dementia: Physiopathological Mechanisms and Clinical Consequences

Alzheimer's disease (AD) is the most common type of dementia, mainly encompassing cognitive decline in subjects aged ≥65 years. Further, AD is characterized by selective synaptic and neuronal degeneration, vascular dysfunction, and two histopathological features: extracellular amyloid plaques composed of amyloid beta peptide (Aβ) and neurofibrillary tangles formed by hyperphosphorylated tau protein. Dementia and AD are chronic neurodegenerative conditions with a complex physiopathology involving both genetic and environmental factors. Recent clinical studies have shown that proton pump inhibitors (PPIs) are associated with risk of dementia, including AD. However, a recent case-control study reported decreased risk of dementia. PPIs are a widely indicated class of drugs for gastric acid-related disorders, although most older adult users are not treated for the correct indication. Although neurological side effects secondary to PPIs are rare, several preclinical reports indicate that PPIs might increase Aβ levels, interact with tau protein, and affect the neuronal microenvironment through several mechanisms. Considering the controversy between PPI use and dementia risk, as well as both cognitive and neuroprotective effects, the aim of this review is to examine the relationship between PPI use and brain effects from a neurobiological and clinical perspective.