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Is it time to stop prescribing PPIs?

Proton pump inhibitors remain a standard treatment for acid-related gastrointestinal problems, but a slew of recent studies have linked the drugs to a worrying range of potential problems.

The latest of these, published this month in the American Journal of Gastroenterology, links PPIs to an increased risk of ischaemic stroke.

The Taiwanese study looked at the stroke risks of 200,000 people on a PPI treatment course compared with a similar number of matched controls. There was a 36% higher risk of stroke during a 120 day follow-up after PPI medication.

Gender, history of myocardial infarction, diabetes, hypertension, NSAID use or type of PPI taken had no effect on the risk.

The researchers cautioned that their study was retrospective and therefore couldn’t prove cause and effect. But they speculated PPIs could increase plasma levels of asymmetric dimethylarginine, which is a risk factor for cardiovascular events.

Here are some other recent studies which have placed a serious question mark over the prescribing of PPIs:

  • A meta-analysis published in JAMA earlier this year found that PPI use increased the risk of recurrent Clostridium difficile infection by more than half.
  • Regular users of PPIs have a 44% greater risk of dementia, according to a German study of 74,000 people aged 75 or older.
  • The Sax Institute’s 45 and Up study showed a 70% increased risk of hospitalisation for infectious gastroenteritis in people using PPIs.
  • PPI use has been linked to chronic kidney damage even in the absence of acute disease. A study compared 125,000 people on PPIs with 18,000 users of H2 blockers, which are generally prescribed for the same conditions. Those on PPIs were much more likely to develop kidney disease.
  • A large Australian study confirmed a link between PPIs and fracture risk. It found 35% of elderly women on PPIs were subsequently diagnosed with osteoporosis, compared with 24% not on PPI therapy.
  • And finally, an Italian study found that people discharged from hospital with a PPI prescription had a 50% higher risk of dying within the year compared with those discharged without PPIs.

PPIs are one of the most commonly prescribed gastric acid suppressants, with over 19 million scripts written annually in Australia.

But the dangers of long-term PPI use is becoming increasingly recognised, with some Australian hospitals insisting on a deprescribing plan for all patients discharged with a PPI script.

Last year, the Gastroenterological Society of Australia published its top five low-value practices and interventions as part of the EVOLVE initiative.

One of these recommendations was to stop prescribing long-term PPIs “without attempting to reduce the medication down to the lowest effective dose or cease the therapy altogether”.