Let’s talk turkey about our pharmaceutical Pet Hates, mine are Proton Pump Inhibitors (PPIs). They irk me more than any other drug class. It’s not entirely rational. Let’s face it, they have some stiff competition but for some reason, in my mind, they almost always win: helping so little & at such a high cost to patients. What fuels my fire of course is their over-prescription, followed closely by the complete disregard for the prescribing guidelines which state:
“When clinically indicated, PPIs should be used for the shortest duration necessary and chronic use is not recommended except for treatment of pathological hypersecretory conditions including Zollinger-Ellison syndrome and maintenance healing of erosive oesophagitis.”
Sorry…did I hear you correctly? Chronic use is not recommended – yet this is one of the drugs most commonly on ‘set and forget mode’ in general practice. To boot, their chronic use has been associated with a number of serious concerns, which I’ve touched on before, from osteoporosis to increased rates of GIT infections. not to mention just the little ol’ detail of malabsorption of multiple nutrients! But this week, yet another health concern has popped up and into my inbox…and well..I found myself shouting at the medical newsfeed on my screen…[again] 🙁
“In their analysis, more than 42,500 adverse events reported to the US Food and Drug Administration by patients on PPI monotherapy were compared with more than 8300 reports from patients on histamine-2 receptor antagonists (H2RAs)….Patients on PPIs alone were 28 times more likely to report chronic kidney disease than those taking H2RAs, while the frequency of acute kidney injury reports was around four times higher…Reports of end-stage renal disease were 35-fold higher among PPI users, while reports of renal nephrolithiasis were three times higher”
To be clear, while these increased rates are TERRIBLE and unacceptable in the context of the ‘set and forget’ prescribing that seems it be rife in most countries, they still only effect a small % of patients e.g. approx 5% of patients had adverse renal effects on PPIs Vs 1% on the older generation H2 blockers for reflux but it’s yet another reason (like we needed more?!) to think twice before our patients are initiated on these meds, which are presented to patients as being benign. Typically with drug development, the older drugs in a class are superseded by newer ones that are ‘cleaner’, and therefore more effective with less adverse effects but this is one situation where if one of my patients really did need a med, I would say out with the new and in with the old!
One scenario where PPIs in combo with multiple antibiotics get routinely rolled out is of course H.pylori infections. But does this make sense??
For a bacteria identified just a few decades ago as being a cause of chronic gastritis, atrophic gastritis and gastric carcinoma, the escalation of number of antibiotics used to eradicate it (4 at last count + PPI) has been nothing short of breathtaking. A management approach more consistent with both integrative medicine and with an improved understanding of the delicate microbiome focuses on changing the gastric environment to ‘remove the welcome mat’. What do we know about how to do this successfully? It turns out…quite a lot. You can find out here with our previous UU30: H.pylori- Eradicate or Rehabilitate?