The Perils of PPIs

1
The Perils of PPIs

• How can they harm us?
• What should they be used for?

2
Quiz

• Which of the following is a result of chronic PPI
  use?
• Increase in fractures
• Increase in CAP
• Increase in risk of C. difficile
• All of the above

3

• If you put all brands of PPIs together, they
  account for 13.9 billion in sales per year.

4
PPIs and Fracture

• PPIs decrease calcium absorption
• JAMA, 2006 nested case control study in a large
  (1.8 million) general practice data base in Great
  Britan. RR of hip fracture was 1.6 in those
  taking PPIs for more than 12 months. The risk
  increased with duration and dose.
• Womens Health Initiative PPI use conferred a
  modestly increased risk of spine, forearm, and
  wrist fractures.
• Other studies have confirmed these findings.
• H2 blockers may or may not increase risk of
  fracture.

5
PPIs and CAP

• Acid reduction may allow pathogens to colonize
  the upper GI tract
• JAMA, 2004 Case control study done in the
  Netherlands of adults on acid suppressive
  therapy. RR for CAP was 1.89 for patients on
  PPIs.
• Archives of Internal Medicine, 2007 Similar
  results in a Danish cohort.
• PPIs also significantly increase the risk of
  hospital acquired pneumonia.
• H2 blockers may have the same effect.

6
PPIs and C. difficile

• Gastric acid lowers the risk of infection.
• Studies looking at both in-patients and people
  living in the community have demonstrated
  increased rates of C. difficile in patients
  taking PPIs. (Also H2 blockers, though less so.)
  RR ranges from 2.1 to 3.5.
• Again, the higher the dose the higher the risk.
• The use of PPIs during treatment for C. difficile
  almost doubles the risk of recurrence.

7
How should PPIs be used?

• For indicated therapies only Peptic ulcer
  disease, eradication of H. pylori, NSAID induced
  ulcers, Zollinger-Ellison syndrome, severe GERD.
• Avoid long term use.
• Avoid supra-therapeutic doses.

8

• How to deal with withdrawal.

9

• Treat underlying disorders
• Taper
• Replace with H2 blockers
• Use non-pharmacologic therapies
• Modify behavior