Proton Pump Inhibitor Use and Adverse Effects in South Atlantic Hospitals

Background

Proton pump inhibitors (PPI) have transformed the management of acid-related gastrointestinal disorders, becoming one of the top-selling medications in the United States. There is no doubt that PPIs have a significant therapeutic impact on patients with gastroesophageal reflux disease and gastrointestinal bleeding. However, evidence is mounting that PPIs are overprescribed, leading to more patients possibly experiencing adverse effects. There is a great deal of ongoing debate surrounding the significance and impact of these adverse effects.

Methods

We conducted a study in 9 HCA hospitals in the southeastern United States to determine the number of patients who started on PPIs during their admission from July 2017 to July 2019 and, of these patients, how many were discharged on PPIs. We also explored whether PPIs were prescribed in conjunction with diagnoses consistent with appropriate use as defined by the National Institute for Health and Clinical Excellence (NICE) guidelines during their admissions. This appropriate use was evaluated based on ICD-10 codes entered during patient stays. Furthermore, we evaluated whether PPI patients had developed some known adverse effects including hypomagnesemia, pneumonia, and Clostridium difficile-associated diarrhea.

Results

Our data showed that of the 52 712 patients included in the study, 53.1% (27 993) received PPIs without evidence of an appropriate diagnosis based on ICD-10 codes. Appropriate use ranged between 36.1% and 62.8% for each hospital included.

Conclusion

PPIs were being overprescribed at the 9 hospitals included in the study according to the ICD-10 codes documented when compared to NICE guidelines. When compared with a normal, age-matched population, our results found increased rates of pneumonia and hypomagnesemia in patients being prescribed PPIs. This study suggests a need to improve hospital PPI prescribing practices to limit the non-indicated administration of PPIs and the resulting increased incidence of adverse effects.

Association between Acid-Lowering Agents, Metformin, and Vitamin B12 among Boston-Area Puerto Ricans

BACKGROUND

Vitamin B12 involves several physiological functions, and malabsorption is reported with medication use.

OBJECTIVES

Studies have reported an inverse association between the use of metformin or acid-lowering agents (ALAs), such as proton pump inhibitors, histamine 2 receptor antagonists, and blood vitamin B12 concentration, because of malabsorption. The concomitant use of these medications is underreported. We sought to examine these associations in a cohort of Boston-area Puerto Rican adults.

METHODS

This analysis was conducted within the Boston Puerto Rican Health Study (BPRHS), an ongoing longitudinal cohort that enrolled 1499 Puerto Rican adults aged 45-75 y at baseline. Our study comprised 1428, 1155, and 782 participants at baseline, wave2 (2.2 y from baseline), and wave3 (6.2 y from baseline), respectively. Covariate-adjusted linear and logistic regression was used to examine the association between baseline medication use and vitamin B12 concentration or deficiency (vitamin B12 <148 pmol/L or methylmalonic acid >271 nmol/L), and long-term medication use (continuous use for ∼6.2 y) and wave3 vitamin B12 concentration and deficiency. Sensitivity analyses were done to examine these associations in vitamin B12 supplement users.

RESULTS

At baseline, we observed an association between metformin use (β = -0.069; P = 0.03) and concomitant ALA and metformin use (β = -0.112; P = 0.02) and vitamin B12 concentration, but not a deficiency. We did not observe associations between ALA, proton pump inhibitors, or histamine 2 receptor antagonists, individually, with vitamin B12 concentration or deficiency.

CONCLUSIONS

These results suggest an inverse relationship between metformin, concomitant ALA, metformin use, and serum vitamin B12 concentration.

Value of 96-hour ambulatory esophageal pH monitoring in the assessment of patients with refractory acid reflux symptoms and their response to anti-reflux diet

Ambulatory esophageal pH monitoring is a diagnostic tool in patients with heartburn and regurgitation. The aim of this study is to evaluate 96-hour esophageal pH monitoring in patients with gastroesophageal reflux disease (GERD), at baseline and under diet that impedes GER. We hypothesized that diet would potentially reduce pathologic acid exposure time (AET). Retrospective series of 88 patients with GERD undergoing wireless 96-hour pH monitoring. Two-day (48 hours) tandem periods, one on liberal, followed by another on restricted diet assessed esophageal AET. Primary end point was >30% reduction in AET while on anti-GER diet. Of the 88 patients, 16 were excluded because of probe migration. Endoscopy and biopsies assessed erosive esophagitis (EE) and Barrett's esophagus (BE), or normal esophagus. Abnormal AET (% pH < 4.0 ≥ 6) further defined nonerosive reflux disease (NERD), whereas normal AET (% pH < 4.0 < 6) with normal endoscopy defined patients as functional heartburn (FH). There were 6 patients with EE (n = 5) and BE (n = 1), 23 with NERD and 43 with FH. Anti-GER diet led to >30% reduction in AET in EE and NERD patients, but not in those with FH. Most patients (n = 43/72; 60%) had FH and could have avoided acid suppression. Furthermore, (14/23; 61%) of patients with NERD completely normalized AET with diet, potentially negating acid suppression. Ninety-six-hour esophageal pH distinguishes GERD patients from those with FH. Fifty percent of EE/BE patients and 61% of those with NERD completely normalize AET with diet. If pathologic AET occurs despite diet, acid suppression is indicated.

Characteristics and Patterns of Proton Pump Inhibitors Prescribing at the Primary Health Care

Background and objectives: the aim of this study was to analyse the utilisation of proton pump inhibitors (PPIs) during a 12-year period and to show the characteristics and patterns of their prescribing. Materials and methods: firstly, in the pharmacoepidemiological analyses the ATC/DDD methodology was used to assess the utilisation of PPIs in the Republic of Srpska. The annual PPI utilisation was expressed as a number of DDD/1000 inhabitants/year. Secondly, the cross-sectional surveys were used to reveal the characteristics of PPIs prescribing and medicines use, namely the dose, duration and indication, and possible adverse reactions. For the purposes of the surveys, the adapted version of questionnaires related to physicians’ and patients’ perspectives of medicines prescribing and use were performed. Results: the utilisation of medicines for alimentary tract and metabolism (group A/ATC classification) increased by almost threefold in a 12-year period, which was consistent with the total medicine utilisation. Pantoprazole was the most prescribed medicine among the PPIs. With the exclusion of PPIs in the therapy of Helicobacter pylori eradication, more than half of family physicians prescribed PPIs with antibiotics, and only 53/239 physicians, noticed some adverse reactions of PPIs in their patients. Most of the patients knew how to use PPIs and were taking these medicines in recommended daily doses, but approximately 45% of them were using PPIs for a long period of time (>6 months). Conclusions: the overuse of PPIs is a major concern due to potential serious adverse reactions, especially in elderly patients and in a case of prolonged exposure.

Proton Pump Inhibitor Use, Hypergastrinemia, and Gastric Carcinoids-What Is the Relationship?

Neuroendocrine tumors (NETs) throughout the body are the focus of much current interest. Most occur in the gastrointestinal tract and have shown a major increase in incidence over the past 30 years, roughly paralleling the world-wide increase in the use of proton pump inhibitor (PPI) drugs. The greatest rise has occurred in gastric carcinoids (g-NETs) arising from enterochromaffin-like (ECL) cells. These tumors are long known to occur in auto-immune chronic atrophic gastritis (CAG) and Zollinger-Ellison syndrome (ZES), with or without multiple endocrine neoplasia type-1 (MEN-1), but the incidences of these conditions do not appear to have increased over the same time period. Common to these disease states is persistent hypergastrinemia, generally accepted as causing g-NETs in CAG and ZES, and postulated as having similar tumorigenic effects in PPI users. In efforts to study the increase in their occurrence, g-NETs have been classified in a number of discussed ways into different grades that differ in their incidence and apparent pathogenesis. Based on a large amount of experimental data, tumorigenesis is mediated by gastrin’s effects on the CCK2R-receptor on ECL-cells that in turn leads to hyperplasia, dysplasia, and finally neoplasia. However, in all three conditions, the extent of response of ECL-cells to gastrin is modified by a number of genetic influences and other underlying risk factors, and by the duration of exposure to the hormonal influence. Data relating to trophic effects of hypergastrinemia due to PPI use in humans are reviewed and, in an attached Appendix A, all 11 reports of g-NETs that occurred in long-term PPI users in the absence of CAG or ZES are summarized. Mention of additional suspected cases reported elsewhere are also listed. Furthermore, the risk in humans may be affected by the presence of underlying conditions or genetic factors, including their PPI-metabolizer phenotype, with slow metabolizers likely at increased risk. Other problems in estimating the true incidence of g-NETs are discussed, relating to non-reporting of small tumors and failure of the Surveillance, Epidemiology, and End Results Program (SEER) and other databases, to capture small tumors or those not accorded a T1 rating. Overall, it appears likely that the true incidence of g-NETs may be seriously underestimated: the possibility that hypergastrinemia also affects tumorigenesis in additional gastrointestinal sites or in tumors in other organ systems is briefly examined. Overall, the risk of developing a g-NET appears greatest in patients who are more than 10 years on drug and on higher doses: those affected by chronic H. pylori gastritis and/or consequent gastric atrophy may also be at increased risk. While the overall risk of g-NETs induced by PPI therapy is undoubtedly low, it is real: this necessitates caution in using PPI therapy for long periods of time, particularly when initiated in young subjects.

[Insufficient symptom control under long-term treatment with PPI in GERD - fact or fiction?]

BACKGROUND

Randomized controlled trials show that patients with gastroesophageal reflux disease (GERD) and treatment with proton pump inhibitors (PPI) in about 30% of the cases complain about persisting reflux symptoms (heartburn, regurgitation). The aim of the study was to evaluate the efficacy of PPI long-term treatment in patients with GERD in the family doctor's office.

METHOD

Patients with GERD and a PPI therapy of at least one year participated in a prospective, multicenter observational study. The patients obtained a questionnaire together with a further prescription of PPI. They were asked about the intensity and frequency of heartburn, regurgitation and sleep disorders due to reflux symptoms, satisfaction with PPI therapy, diagnostics performed up to now (endoscopy, pH monitoring, manometry) and surgical consultation. The questionnaire included a validated instrument for the diagnosis of GERD (GerdQ). Patients with the diagnosis "GERD " according to the questionnaire who were very dissatisfied with their current PPI therapy (score 1 or 2 on a 5-point Likert scale) were defined as "lost patients " (LOPA).

RESULTS

39% of the patients still suffered from heartburn at least two days a week, 30% of regurgitation. In 22% of the patients, reflux symptoms led to sleep disorder at least two days a week. 20% of the patients were very dissatisfied with the current PPI therapy. 70% of them (= 14% of the total patient population) were "lost patients " according to the definition. An endoscopy was performed in 86% of the patients and function diagnosis (pH monitoring ± manometry) in 8%. A surgeon was consulted in 8% of the patients, a third of which had received function diagnosis before.

CONCLUSIONS

A poor symptom control can often be found in GERD patients with PPI long-term therapy, but does not stand out in the daily routine. So diagnosis will not continue and treatment alternatives will not be searched for. In the future quality of treatment should be verified e. g. by questionnaires.

Connections between nutritional status and proton pump inhibitor therapy in patients scheduled for cardiovascular rehabilitation after treatment for ischaemic and valvular heart disease

BACKGROUND

Multiple and yet uncertain connections exist between cardiovascular diseases and the nutritional status of patients, particularly in relation to cardiovascular treatments. Proton pump inhibitors (PPI) are among the most commonly used group of drugs.

AIM

To analyse utilisation of PPI in association with nutritional risk of patients scheduled for rehabilitation after treatment for ischaemic and valvular heart disease.

METHODS

Retrospective analyses on a consecutive sample of patients, which included drug utilisation of PPI and nutritional risk screening, using a standardised NRS-2002 tool. The patients (n = 536) were divided into groups based on previous cardiovascular treatments and use of PPI.

RESULTS

Nearly half of the patients (244, 46.1%) had PPI in their chronic therapy despite the clinically negligible prevalence of conditions that are their fundamental indications. The odds for using PPI in patients with increased nutritional risk, estimated by logistic regression, were 3.34 (95% confidence intervals [CI] 2.26-4.94), p < 0.001. Receiver operating curve analyses also revealed significant differences of PPI utilisation in connection with NRS-2002 > 3: positive likelihood-ratio (LR) 2.35 (95% CI 2.10-2.60); negative LR 0.46 (95% CI 0.4-0.6); area under the curve (AUC) 0.720; p < 0.001; as well as the percentage weigh loss history > 6.36% (positive LR 2.22 [95% CI 2.00-2.50]; negative LR 0.41 [95% CI 0.30-0.50]; AUC 0.707; p < 0.001).

CONCLUSIONS

Utilisation of PPI was found to be of relatively high prevalence and significantly associated with parameters of nutritional risk screening. Furthermore, it was in correlation with the age of patients and the existence of chronic kidney disease, which are well-established predispositions for poor nutritional status. Nutritional risk seems to be additionally negatively challenged by utilisation of PPI due to gastric malabsorption and anaemia.