Let’s talk about proton pump inhibitors (PPIs). These drugs, successors to the innovative H2 blockers, have revolutionized the treatment of gastro-esophageal reflux disease (GERD) and peptic ulcers.
But like all good things, too much can be a problem, and that’s where we are today.
A new study shows that of 90 patients who were tested and found NOT to have GERD, 38 (42%) continued to take PPIs that had been prescribed prior to the testing. Some, apparently, were not always told to stop the medication, and others continued it because they remained symptomatic.
Ambulatory patients are not the only ones overusing PPIs. According to UpToDate, the indications for stress ulcer prophylaxis in hospitalized patients are as follows:
Mechanical ventilation for more than 48 hours, coagulopathy, GI ulceration or bleeding within the past year, traumatic brain injury, traumatic spinal cord injury, severe burns, or two or more minor risk factors, including sepsis, ICU admission lasting >1 week, occult GI bleeding lasting ≥6 days, or high-dose glucocorticoid therapy.
But in most hospitals, intravenous PPIs are routinely ordered for any patient who is NPO (not taking food or drink by mouth). There is not one shred of evidence that PPIs are indicated in this setting. I am old enough to remember the days before PPIs and H2 blockers existed. I assure you that millions of patients were NPO and did not develop gastritis or ulcers.
Of course, PPIs are available over the counter (OTC) now, and although they are meant to be taken for only 3 weeks at a time and for no more than 3 such courses per year, there is really no limit to the number of PPIs purchased and used.
In 2010, an estimated $11.4 billion of prescription PPIs alone were sold. The amount of OTC drugs sold is not included, but Consumer Reports noted that in 2009, Nexium OTC sales amounted to $6.3 billion.
Among the adverse effects associated with PPIs reported in a recent systematic literature review are these:
– Clostridium difficile-associated diarrhea
– Community-acquired pneumonia
– Osteoporotic fracture
– Vitamin B12 deficiency
– Inhibition of antiplatelet therapy
Other studies show that hospital-acquired pneumonia may also be more frequent in patients on PPIs.
Many experts feel that the current epidemic of C. diff colitis is being fueled not only by the indiscriminate use of antibiotics, but also by the overuse of PPIs.
How can the overuse of PPIs be stopped? When I was teaching residents, I tried to confront them with the evidence of harm and lack of evidence of utility of PPIs for patients who were simply NPO. It didn’t seem to matter. Someone or something had gotten into their heads, and I couldn’t convince them.
I can’t count the number of outpatients I see who say they are on PPIs for GERD or “gastritis” but have never had a proper workup to establish those diagnoses. I have no idea how to stop the wholesale use of PPIs by primary care MDs, gastroenterologists and people who self-medicate.
It may be hopeless.
Skeptical Scalpel is a practicing surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For almost 2 years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog has had more than 200,000 page views, and he has over 2,800 followers on Twitter.
SkepticalScalpel
Hi,
I took Nexium for three-four years and found out through articles etc.. That you should not take it over 8 months. I was a healthy 50 year old six mile a day runner, bike rider and did Pilates on the reformer for ten years. I had H. Pylori bacteria and was treated with Nexium for tge Gerd but left on it for too many years. I broke my left ankle, left tibia, had a knee replacement due to too much hardware placed in leg and recently broke my left femur at the ball and had three screws placed at that point and had them removed two weeks ago to enable the knee to function properly. The knee replacement and femur surgery were completed by leading orthopedists at NYU. It has been a long three years if recuperation and I am still learning how to walk normally again. Is there proof that Nexium can cause a decrease in bone density? I am taking Forteo shots daily for two years due to severe osteoporosis and the bone density of an 80 year old woman with many possible side effects of Forteo. Could you tell me where I could find concrete articles on this topic and PPIs?
Thank you!
just a few months ago I realized much to my horror, since I have been collecting red wine for the last 30 year, that wine, and in particular, red wine gave me what I experienced as excessive stomach acid which presented as pain in my gut. My ENT doc prescribed a PPI which, happily, solved the problem. But, now I find that my energy level is noticably less, to the point that I find myself taking a nap after breakfast. I wonder if I am not effectively metabolizing my intake.
Taghi, I agree that when used properly, PPIs are beneficial. But the New York Times, in an article from two days ago, agrees with my contention that PPIs are overused and dangerous.
Here’s a link to that article: http://well.blogs.nytimes.com/2012/06/25/combating-acid-reflux-may-bring-host-of-ills/?ref=health
The GERD needs to be treated effectively to prevent further complications such as ulceration, stricture, metaplasia, carcinoma and improvement of quality of life. Yes, medications have side effects but the benefit when outweighs the harm should be used in my opinion.
I am a healthy 63 year old who had GERD at age 45. I took PPSs for two months to suppress the acid flowing up my esophagus into my throat. The PPSs did nothing to stop the bile and food that also traveled up my food tube. Medical therapy treats the symptoms – not the cause of the GERD.
After the two months of taking PPS’s, I was able to have a Nissen Fundoplication performed by a competent surgeon. My wrap is long and tight (6 centimeters long with 5 braided polyester sutures at the union). I have had 18 years of zero acid reflux or heartburn. My bones are strong and I have plenty of energy. I think PPIs should only be taken for moderate periods of time and not indefinitely. In my opinion medical therapy cannot offer a “cure.” Surgical therapy, such as the Nissen Fundoplication, can and does offer a cure for GERD when the cause is a weak LES that fails to close the food tube and prevent reflux.
John, thanks for commenting. You are correct that PPIs do not cure GERD. They merely alleviate some of the symptoms. You had a very good outcome of the surgery.