PPIs Are Not Responsible for Elevating Cardiovascular Risk in Patients on Clopidogrel-A Systematic Review and Meta-Analysis

Optimizing antithrombotic therapy in patients with coexisting cardiovascular and gastrointestinal disease

Balancing the safety and efficacy of antithrombotic agents in patients with gastrointestinal disorders is challenging because of the potential for interference with the absorption of antithrombotic drugs and for an increased risk of bleeding. In this Review, we address considerations for enteral antithrombotic therapy in patients with cardiovascular disease and gastrointestinal comorbidities. For those with gastrointestinal bleeding (GIB), we summarize a general scheme for risk stratification and clinical evidence on risk reduction approaches, such as limiting the use of concomitant medications that increase the risk of GIB and the potential utility of gastrointestinal protection strategies (such as proton pump inhibitors or histamine type 2 receptor antagonists). Furthermore, we summarize the best available evidence and potential gaps in our knowledge on tailoring antithrombotic therapy in patients with active or recent GIB and in those at high risk of GIB but without active or recent GIB. Finally, we review the recommendations provided by major medical societies, highlighting the crucial role of teamwork and multidisciplinary discussions to customize the antithrombotic regimen in patients with coexisting cardiovascular and gastrointestinal diseases.

Does the long-term administration of proton pump inhibitors increase the risk of adverse cardiovascular outcomes? A ChatGPT powered umbrella review

BACKGROUND

Proton pump inhibitors (PPIs) are commonly prescribed for the treatment of acid-related disorders. In the context of coronary artery disease (CAD), PPIs are commonly prescribed along with antiplatelet medications. In fact, the potential interaction between these two classes of medications has been subject to much debate. This review aimed to summarise the findings from systematic reviews and meta-analyses on the casual relationship between PPI use (alone) and major adverse cardiovascular events (MACE). Furthermore, the recent release of ChatGPT has provided reviewers with a powerful natural language processing tool. We therefore aimed to assess the utility of ChatGPT in the systematic review process.

METHODS

A comprehensive search of PubMed was conducted to identify relevant systematic reviews and meta-analyses published up to March 2023. Two independent reviewers assessed the eligibility of the studies, extracted the data, and assessed the methodological quality using AMSTAR 2.0. The population of interest was adults that received the medications of interest (PPIs) for a minimum of three months, regardless of indication. Control groups were defined as placebo or active comparators. The outcomes of interest were described under the general term MACE, which include cardiovascular death, non-fatal myocardial infarction, and non-fatal stroke. There were no restrictions with regards to time, but we only included reports in English. A different group of independent reviewers simultaneously ran the same process using ChatGPT. The results were then compared with the human generated results.

RESULTS

Seven systematic reviews and meta-analyses were included, involving a total of 46 randomised controlled trials and 33 observational studies. The studies examined the association between PPI use and MACE, including stroke, myocardial infarction, and all-cause mortality. The results of the individual studies were conflicting, with some showing a positive association between PPI use and MACE, some showing no association, and others showing mixed results. However, the majority of the studies that included observational data reported a positive association between PPI use and MACE. Sensitivity analyses conducted in some studies did not significantly alter the primary results, suggesting that the findings were robust. Furthermore, ChatGPT was successfully prompted to execute most tasks involved in this review. We therefore present text that was generated by ChatGPT, including the abstract, introduction, results, and discussion sections.

CONCLUSION

The findings of this umbrella review suggest that a causal relationship between PPI use and an increased risk of MACE cannot be ruled out. Further research is needed to better understand this relationship, particularly the underlying mechanisms and potential confounding factors. Healthcare professionals should consider the long-term use of PPIs and carefully weigh the risks and benefits for each patient. Finally, ChatGPT was successfully prompted to execute most of the tasks involved in this review. We therefore feel that this tool will be of great assistance in the field of evidence synthesis in the near future.

Prevalence and Safety of Prescribing PPIs with Clopidogrel in Palestine

BACKGROUND

Proton pump inhibitors (PPIs) are commonly prescribed medications that are thought to increase the risk of cardiovascular events because they reduce the effectiveness of clopidogrel via shared hepatic pathways.

OBJECTIVE

This study examined the prevalence of concomitant prescribing of clopidogrel/PPI among patients diagnosed with acute coronary syndrome and the adverse cardiovascular event associated with this interaction.

METHODS

A retrospective cohort study was conducted by retrieving patient data from the Nat Health Insurance claims processor database in Palestine. Adults diagnosed with Acute Coronary Syndrome (ACS) from 2019 through 2021 who were prescribed clopidogrel or clopidogrel in combination with a PPI were included in the study. Endpoints were adverse cardiac events, including readmission for revascularization during the first year of treatment.

RESULTS

The study included 443 patients; the prevalence of prescribing concomitant clopidogrel with a PPI was 74.7%, whereas 49.2% were prescribed interacting PPI (omeprazole, esomeprazole, and lansoprazole). 59 (13.3%) of participants experienced a cardiovascular event within 1 year of starting therapy, including 27 (12.4%) patients who had a cardiovascular event while taking an interacting PPI. No significant association was found between PPI administration and increased CV event risk in patients receiving concomitant clopidogrel and PPIs therapy (p = 0.579).

CONCLUSION

In this study, we observed a high prevalence of prescribing a PPI in combination with clopidogrel, regardless of the FDA recommendations. No significant increase in cardiovascular events was observed in patients receiving concomitant clopidogrel and PPI therapy.

Risks of long-term use of proton pump inhibitor on ischemic vascular events: A distributed network analysis of 5 real-world observational Korean databases using a common data model

BACKGROUND

Proton pump inhibitors (PPIs) are frequently prescribed drugs. However, it has been suggested that they are associated with an increased risk of ischemic vascular events (IVE) including stroke, although the data are inconsistent.

AIMS

We investigated the association between PPIs use and IVE in five observational Korean databases using a common data model (CDM).

METHODS

This study included patient-based retrospective, observational cohort data of subjects aged over 18 years between January 1, 2004, and December 31, 2020, from five medical centers as part of the Observational Medical Outcomes Partnership (OMOP) CDM. Subjects who were included in both cohorts or had a previous history of ischemic stroke were excluded. After propensity matching, 8007 propensity-matched pairs between the PPIs and H₂ receptor antagonist (H₂RA) users were included in this study.

RESULTS

In the 1:1 propensity score matching with 8007 in each group, long-term PPIs use (⩾365 days) was not associated with ischemic stroke (odds ratio (OR) = 1.05, 95% confidence interval (CI) 0.71-1.56; I² = 57%), ischemic stroke and transient ischemic attack (OR = 1.02, 95% CI 0.71-1.48; I² = 53%), and net adverse clinical events (OR = 1.08, 95% CI 0.83-1.40; I² = 47%) compared with H2RAs users.

CONCLUSIONS

Our analysis in a large dataset found no evidence that long-term use of PPIs was associated with an increased risk of ischemic stroke.

Acid suppressants use and risk of atherosclerotic cardiovascular disease in middle-aged and older adults

BACKGROUND AND AIMS

Concerns regarding adverse events associated with the use of acid suppressants have increased. However, the impact of proton pump inhibitors (PPIs) and histamine-2 receptor antagonists (H2RAs) on the risk of atherosclerotic cardiovascular disease (ASCVD) remains unknown. This study aimed to estimate the risk of ASCVD in association with the use of PPIs and H2RAs.

METHODS

This prospective cohort study included participants without cardiovascular diseases or anti-hypertensive treatment at baseline (2006-2010) in the UK Biobank. The outcomes were ASCVD and each subtype (coronary artery disease, myocardial infarction, peripheral artery disease, and ischemic stroke). The association was estimated by Cox proportional-hazards models.

RESULTS

Among 316,730 individuals (aged 50-88 years), during a median of 12.5 years of follow-up, we documented 13,503 (4.3%) incident ASCVD. Regular PPIs use was associated with a higher risk of ASCVD (HR: 1.16, 95% CI: 1.09-1.23) and every subtype of ASCVD. Among each type of PPIs, omeprazole (HR: 1.19, 95% CI: 1.11-1.28), lansoprazole (HR: 1.11, 95% CI: 1.02-1.22), and pantoprazole (HR: 1.40, 95% CI: 1.00-1.97) were associated with a higher risk of ASCVD. Stratification analysis showed that PPIs use was associated with a higher risk of ASCVD among individuals without indications of medications for PPIs. In addition, use of H2RAs was not related to the risk of ASCVD (HR: 0.97, 95% CI: 0.85-1.11).

CONCLUSIONS

PPIs were associated with increased risk of ASCVD, particularly amongst participants without indications for medication. Our findings are of important practical significance and suggest that clinicians should be cautious in prophylactic use of PPIs.

An update on drug-drug interactions associated with proton pump inhibitors

INTRODUCTION

Proton pump inhibitors (PPIs) block the gastric H/K-ATPase, therefore inhibiting acid gastric secretion, leading to an increased pH (>4). They account for an extremely high number of prescriptions worldwide. Numerous drug-drug interactions have been described with PPIs, but all the described interactions do not have clinical significance.

AREAS COVERED

This review will discuss the latest updates on drug-drug interactions with PPIs, focusing on the last ten-year publications in the following areas: anti-infective agents, anticancer drugs, antiplatelet agents and anticoagulants, and antidiabetics.

EXPERT OPINION

Although pharmacokinetic interactions of PPIs have been described with many drugs, their clinical relevance remains controversial. However, given the extremely high number of people being treated with PPIs, clinicians should remain vigilant for interactions that may be clinically significant and require dose adjustment or therapeutic monitoring. Interestingly, not all PPIs have the same pharmacokinetic and pharmacodynamic profile, with some having a strong potential to inhibit CYP2C19, such as omeprazole, esomeprazole and lansoprazole, while others, pantoprazole, rabeprazole and dexlansoprazole, are weak CYP2C19 inhibitors. These may be preferred depending on co-prescribed treatments.In addition, new formulations have been developed to prevent some of the gastric pH-dependent drug interactions and should be evaluated in further large-scale prospective comparative studies.

Factors Associated with Platelet Activation-Recent Pharmaceutical Approaches

Platelets are at the forefront of human health and disease following the advances in their research presented in past decades. Platelet activation, their most crucial function, although beneficial in the case of vascular injury, may represent the initial step for thrombotic complications characterizing various pathologic states, primarily atherosclerotic cardiovascular diseases. In this review, we initially summarize the structural and functional characteristics of platelets. Next, we focus on the process of platelet activation and its associated factors, indicating the potential molecular mechanisms involving inflammation, endothelial dysfunction, and miRs. Finally, an overview of the available antiplatelet agents is being portrayed, together with agents possessing off-set platelet-inhibitory actions, while an extensive presentation of drugs under investigation is being given.

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.

Association of proton-pump inhibitor use with adverse health outcomes: A systematic umbrella review of meta-analyses of cohort studies and randomised controlled trials

AIMS

The aim was to perform an umbrella review to summarise the existing evidence on proton-pump inhibitor (PPI) use and adverse outcomes and to grade the certainty of evidence.

METHODS

Electronic databases were searched up to July 2021 for meta-analyses of cohort studies and/or randomised controlled trials (RCTs). Summary effect sizes from a random-effects model, between-study heterogeneity, 95% prediction interval, small-study effect, excess significance and credibility ceilings were devised to classify the credibility of evidence from meta-analyses of cohort studies, whereas the GRADE approach was used for meta-analyses of RCTs.

RESULTS

In meta-analyses of cohort studies, 52 of the 91 examined associations were statistically significant (P ≤ .05). Convincing evidence emerged from main analysis for the association between PPI use and risk of all-site fracture and chronic kidney disease in the elderly population. However, none of these associations remained supported by convincing evidence after sensitivity analyses. The use of PPI is also associated with an increased risk of mortality due to COVID-19 infection and other related adverse outcomes, but the quality of evidence was weak. In meta-analyses of RCTs, 38 of the 63 examined associations were statistically significant. However, no associations were supported by high or moderate-quality evidence.

CONCLUSION

This study's findings imply that most putative adverse outcomes associated with PPI use may not be supported by high-quality evidence and are likely to have been affected by underlying confounding factors. Future research is needed to confirm the causal association between PPI use and risk of fracture and chronic kidney disease.

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.

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.

Clinical Outcomes of Concomitant Use of Proton Pump Inhibitors and Dual Antiplatelet Therapy: A Systematic Review and Meta-Analysis

Background: The safety and efficacy associated with the use of proton pump inhibitors (PPIs) by patients with coronary artery disease receiving dual antiplatelet therapy (DAPT) remain unclear.

Methods: The evaluated outcomes included combined major adverse cardiovascular events (MACEs), myocardial infarction (MI), all-cause mortality, and gastrointestinal (GI) bleeding. A random effects meta-analysis, stratified by study design, was performed and heterogeneity was assessed using the I² statistic.

Results: In total, 6 randomized controlled trials (RCTs) (6930 patients) and 16 observational studies (183,546 patients) were included. Analysis of RCTs showed that there were no significant differences in the incidences of MACEs (risk ratio [RR] = 0.89 [95% confidence interval (CI) = 0.75–1.05]), MI (RR = 0.93 [95% CI = 0.76–1.15]), and all-cause mortality (RR = 0.79 [95% CI = 0.50–1.23]) in the PPI groups vs. the non-PPI groups. Pooled data from observational studies revealed an inconsistent association between the use of each PPI subtype and the increased risks of MACEs during clopidogrel treatment. There was no increased risk of MACEs or all-cause mortality associated with the use of PPIs (as a class) and other P2Y₁₂ inhibitors. Both the RCTs and observational studies revealed that the use of PPIs significantly reduced the risks of GI bleeding.

Conclusion: The use of PPIs was associated with a reduced risk of GI bleeding in patients treated with DAPT after percutaneous coronary intervention or acute coronary syndrome. There was no clear evidence of an association between the use of PPIs and adverse cardiovascular events.

Clinical Trial Registration: identifier [CRD42020190315]

Proton Pump Inhibitor and Clopidogrel Use After Percutaneous Coronary Intervention and Risk of Major Cardiovascular Events

PURPOSE

Due to shared hepatic metabolism, concomitant medication with a proton pump inhibitor (PPI) and clopidogrel might reduce the effectiveness of clopidogrel in the prevention of cardiovascular events after percutaneous coronary intervention (PCI). We aimed to examine the risk of major cardiovascular events after PCI comparing patients who used clopidogrel together with PPI with those who used clopidogrel alone.

METHODS

This Swedish nationwide cohort study included patients who received clopidogrel after primary PCI in 2005-2019. Patients were followed for up to 12 months after PCI. Data were retrieved from the Swedish Prescribed Drug Registry, Patient Registry, Cancer Registry, and Cause of Death Registry. Multivariable Cox regression provided hazard ratios (HRs) with 95% confidence intervals (CIs) for cardiovascular events comparing PPI users (exposed) with non-users of PPI (non-exposed). The HRs were adjusted for sex, age, comorbidity, calendar period, obesity, diabetes, anti-diabetic medication, tobacco-related diseases, hypertension, and congestive heart failure.

RESULTS

The cohort included 99,836 patients who received clopidogrel after primary PCI. Among these, 35,772 (35.8%) received concomitant PPI. Compared to non-users, PPI users had increased adjusted HRs of all study outcomes, i.e., the main outcome myocardial infarction (HR = 1.23, 95% CI 1.15-1.32) and the secondary outcomes coronary heart disease (HR = 1.28, 95% CI 1.24-1.33), stroke (HR = 1.21, 95% CI 1.05-1.40), and death due to coronary heart disease (HR = 1.52, 95% CI 1.37-1.69). The results were similar in analyses including both primary and secondary PCIs.

CONCLUSIONS

In patients who receive clopidogrel after PCI, concomitant use of PPI seems to increase the risk of major cardiovascular events.

Omeprazole-clopidogrel interaction and neurovascular complications after flow-diverter device placement

BACKGROUND

Omeprazole is a common proton pump inhibitor that interferes with the hepatic activation of clopidogrel and potentially reduces its platelet-inhibitory effect. Omeprazole has been shown to increase P2Y₁₂ levels and adverse cardiovascular outcomes in patients treated with drug-eluting stents. However, omeprazole use among patients treated with flow-diverting stents for intracranial aneurysms has not been evaluated.

METHODS

All patients with placement of a flow-diverting device for treatment of an intracranial aneurysm at a tertiary institution from January 1, 2014, to December 31, 2018, were retrospectively analyzed. Inclusion criteria included documented clopidogrel administration, available P2Y₁₂ levels, and thorough documentation of administration of other medications, including omeprazole.

RESULTS

A total of 138 patients met the inclusion criteria. Sixteen patients (12%) were receiving omeprazole and clopidogrel at treatment. P2Y₁₂ reactivity was significantly greater in the omeprazole cohort (mean P2Y₁₂ level, 250 P2Y₁₂ reaction units (PRU)) than in the control cohort (mean P2Y₁₂ level, 112PRU) (P<0.001). Furthermore, a greater proportion of patients had a P2Y₁₂ level >180 PRU in the omeprazole cohort (14 of 16 [88%] vs 24 of 122 [20%]; P<0.001; OR [95% CI], 29 [6-134]).

CONCLUSION

Omeprazole was associated with a significant increase in the mean P2Y₁₂ reactivity level among patients with intracranial aneurysms treated with flow-diverting devices who received clopidogrel. However, receipt of omeprazole was not associated with an increased risk of ischemic events or stent stenosis. For neuroendovascular patients who are treated with a flow diverter while receiving clopidogrel, alternative gastrointestinal medication regimens should be considered.

Trials of Dual Antiplatelet Therapy After Percutaneous Coronary Intervention Lack Strategies to Ensure Appropriate Gastroprotection

INTRODUCTION

Gastrointestinal bleeding is a morbid complication of dual antiplatelet therapy (DAPT). We evaluated the extent to which contemporary trials of DAPT included steps to ensure appropriate use of proton pump inhibitor (PPI) gastroprotection and reported rates of PPI use.

METHODS

A methodological review of randomized trials comparing varying durations of DAPT after percutaneous coronary intervention.

RESULTS

Among 21 trials, none incorporated protocol procedures or guidance for prescribing PPIs. Five reported rates of PPI use (range 25.6-69.1%).

DISCUSSION

PPI gastroprotection is overlooked in major trials of DAPT. Appropriate use of PPI gastroprotection represents an important opportunity to improve patient safety.

Proton pump inhibitors and risk of all-cause and cause-specific mortality: A cohort study

AIM

To investigate the association between proton pump inhibitors (PPIs) and both all-cause and cause-specific mortality.

METHODS

We conducted a cohort study using the UK Clinical Practice Research Datalink GOLD database. We compared 733 885 new users of PPIs to 124 410 new users of H2 receptor antagonists (H2Ras). In a secondary analysis we compared 689 602 PPI new users to 1 361 245 nonusers of acid suppression therapy matched on age, sex and calendar year. Hazard ratios for all-cause and cause-specific mortality were estimated using propensity score (PS) weighted Cox models.

RESULTS

PPI prescription was associated with increased risk of all-cause mortality, with hazard ratios decreasing considerably by increasing adjustment (unadjusted hazard ratio [HR] 1.65, 95% confidence interval [CI] 1.62-1.69; PS-weighted HR 1.38, 95% CI 1.33-1.44; high-dimensional PS-weighted HR 1.31, 95% CI 1.26-1.37). Short-term associations were observed with mortality from causes where a causal short-term association is unexpected (eg, lung cancer mortality: PS-weighted HR at 6 months 1.77, 95% CI 1.39-2.25). Adjusted hazard ratios were substantially higher when compared to nonusers (PS-weighted HR all-cause mortality 1.96, 95% CI 1.94-1.99) rather than H2RA users.

CONCLUSIONS

PPI prescription was strongly associated with all-cause and cause-specific mortality. However, the change in hazard ratios (a) by increasing adjustment and (b) between comparator groups indicates that residual confounding is likely to explain the association between poor health outcomes and PPI use, and fully accounting for this using observational data may not be possible.

The Use and Misuse of Proton Pump Inhibitors: An Opportunity for Deprescribing

Proton pump inhibitors (PPIs) are proven medications of choice for gastroesophageal reflux disease (GERD), acid-related disorders, erosive esophagitis, Barrett esophagus, prevention of gastrointestinal bleeding while on nonsteroidal anti-inflammatory drugs, eosinophilic esophagitis, peptic ulcer disease, stress ulcer prophylaxis in critically ill patients, and other indications. Best practice guidelines from several sources on the appropriate indications and duration of PPI therapy have been summarized for easy assimilation. Individualized decision with regard to PPI use is illustrated by case vignettes; best approaches are provided. The significant increase in use of PPIs for ill-defined indications over the years, associated adverse outcomes with long-term use, and consequent increase in health care costs have drawn much attention. Adverse outcomes due to PPI therapy may be categorized as unrelated or related to gastric acid inhibition. Examples of outcomes unrelated to acid inhibition include allergic reactions, acute interstitial nephritis, chronic kidney disease, poor cardiovascular outcomes, dementia, and drug interactions; consequences of acid inhibition include gastrointestinal infections, pneumonia, nutrient deficiencies, fractures, spontaneous bacterial peritonitis, and small intestinal bacterial overgrowth. Provider awareness regarding best practice guidelines on PPI use and imparting pertinent education to patients may be the rational approach to safe and effective PPI therapy. In individuals in whom the drug is not indicated, efforts at deprescribing the PPI may be attempted following discussion with the patient. Approaches include stopping the drug, reducing the dose or using "on-demand" therapy after completing the course of treatment for the specific indication. Barriers to successful deprescribing exist. Follow-up is recommended for recurrence of manifestations; in the event of recurrence, the PPI may need to be re-instituted. PPIs are valuable, irreplaceable drugs in the prevention and treatment of certain disorders for specific durations of time. Evidence nevertheless suggests that excessive and inappropriately prolonged use of PPIs is associated with a broad range of adverse effects. Education of provider and patient, stewardship, and motivation are key to appropriate use of PPIs for the right indications. Key implications for practice are offered.

Side effects of drug treatments for gastro-oesophageal reflux disease: current controversies

The two main drugs used in the treatment of gastro-oesophageal reflux disease are proton pump inhibitors and histamine-2 receptor antagonists and both these agents have been implicated in a number of adverse effects, leading to considerable controversies related to their long-term use. This paper is aimed at a critical review of the published literature and the clinical significance of these reported side effects, most of which are associations rather than causal.

Long-term use of proton pump inhibitors as a risk factor for various adverse manifestations

The long-term use of proton pump inhibitors (PPIs) can lead to increased gastric pH, hypochlorhydria and in some cases to achlorhydria when compared to other acid-suppressing agents like histamine-2 (H2) receptor blockers and antacids. These consequences by the use of long-term PPIs may lead to significant vitamin (B₁₂ and C) and mineral (iron, calcium and magnesium) deficiencies which needs gastric acid for their absorption and bioavailability. Long-term use of PPIs by the pregnant patients may impose a potential risk of congenital malformations. Various studies have recommended the life style modifications and antacid use as first choice among pregnant womens by preserving PPIs (omeprazole as a safe choice of PPI) for severe conditions of gastroesophageal reflux disease. The long-term acid suppression by PPIs can also lead to enteric, respiratory and urinary tract infections. The hypochlorhydria by chronic PPIs use may induce hypergastrinemia, which ultimately mediates the gastric polyps, gastric carcinoids and gastric cancer. The concomitant use of PPIs with antiplatelet drugs like clopidogrel can impose the patients to major adverse cardiac events. This review has enlisted the comprehensive information regarding the adverse effects induced by long-term use of PPIs and their possible relations. Considerable studies like case-control, randomized trials, cohort studies and meta-analysis were reported in supporting these adverse effects. The clinicians and patients should be cautious about these effects so that they can avoid the serious outcomes. PPIs should be avoided for long-term use mainly in older adults unless there is a proper indication.

Proton pump inhibitors and risk of liver cancer and mortality in patients with chronic liver disease: a systematic review and meta-analysis

BACKGROUND

Epidemiological studies investigating the use of proton pump inhibitors (PPI) on the risk of liver cancer and/or mortality among persons with chronic liver disease (CLD) have reported conflicting results. We conducted a systematic review and meta-analysis to determine the impact of PPI use on liver cancer and/or death among patients with CLD.

METHODS

The core databases including MEDLINE, EMBASE, and Cochrane library were searched through January 2020. We included studies, evaluating the association between PPIs and liver cancer or mortality among patients with CLD including randomized controlled, nonrandomized controlled, and observational studies. We used inverse-variance random-effects models to estimate the pooled relative risk (RR) and 95% confidence interval (CI) for liver cancer or mortality.

RESULTS

Eleven studies including 173,894 patients were selected. In three studies, individuals with CLD who used PPIs had a 67% greater risk of developing hepatocellular carcinoma (HCC) compared to nonusers (RR, 1.67; 95% CI, 1.12-2.50; I² = 92%). Combining data from the eight studies relating PPI to overall mortality, we observed a 57% increased risk of mortality in PPI users with CLD compared to CLD nonusers (RR: 1.57; 95% CI, 1.24-1.99; I² = 69%).

CONCLUSION

PPI use was associated with an increased risk of HCC and mortality in patients with CLD suggesting that PPI prescriptions in patients with CLD should be considered carefully.

Proton pump inhibitors and cardiovascular adverse effects: Real or surreal worries?

Proton pump inhibitors (PPIs) are among the most widely prescribed agents, either for treatment or prophylaxis of gastrointestinal (GI) disease, that are often administered for prolonged or chronic use. Patients with cardiovascular (CV) disease frequently receive PPIs for prophylaxis against GI bleeding due to common use of antithrombotic drugs. Over the last several years there is a growing number of reports associating chronic PPI use with a variety of serious CV and non-CV adverse effects. In this context, PPI use has been independently associated with an increased risk of CV morbidity (myocardial infarction, stroke, other CV events) and mortality. However, the critique remains that these data do not largely derive from randomized controlled trials. On the other hand, in certain conditions, the benefits of PPIs may outweigh the risks of adverse CV effects. As the indications for prolonged, particularly lifelong, prophylactic use of PPIs are not compelling and in the light of evidence of serious CV and other adverse effects, clinicians have to reconsider such long-term use of these drugs. Importantly, histamine 2 blockers have not been found to be associated with increased CV risk and thus may be an alternative therapeutic option in certain patients. These issues are amply discussed together with the potential mechanisms of these pleiotropic and off-target effects of PPIs, which are also depicted in an illustrative schema; data are also presented on differential effects of specific agents involved, alternative modes of therapy available, and relevant current guidelines on this issue.