Risk of Acid Suppression Therapy
By David Edwards, MD, Chief Medical Officer
During my career, I have seen HIV infection go from a uniformly fatal disease to one that can be controlled. But even more remarkable has been the effect of acid suppression therapy and the treatment of Heliobacter Pylori on gastric and duodenal ulcer disease.
I remember holding retractors while surgical residents were taught Bilroth 1 and Bilroth 2 procedures by hand (my attending felt the new staplers make them lazy). In a few short years (okay I've been out of medical school little longer than that), these relatively common surgical procedures are very rarely done. The pendulum for acid suppression therapy however is swinging back. The relatively indiscriminate use has led to significant complications that we have only recently recognized.
Acid suppression therapy (AST) in the form of PPIs or H2 receptor blockers is one of the most commonly prescribed classes of medications in hospitalized patients. The American Society of Health System Pharmacists guidelines for stress ulcer prophylaxis (SUP) states that SUP is not recommended for adult general medical and surgical patients in non-ICU settings, yet 70 percent of hospitalized patients were started on AST upon admission. Of these, 73 percent lacked a substantiating diagnosis. Sixty-nine percent of patients started on inappropriate AST were discharged on the same regimen. Admitting diagnosis, age of patient, length of stay, or concomitant use of ulcerogenic drugs does not predict continuation of unnecessary AST at discharge.
Numerous risks are associated with prolonged and potentially non-judicious use of PPIs as described in the American Journal of Gastroenterology. The following risks are statistically significant:
- Clostridium difficile -associated diarrhea for which the FDA has issued a Med Watch for the public.
- Community- acquired pneumonia
- Hip fracture
- Appropriate absorption of medications that are pH-dependent can be affected by PPIs, resulting in altered rates of absorption. Such medications include ketoconazole, digoxin, nifedipine, indinavir, midazolam, didanosine, methadone, and aspirin
- Several reported cases of hypomagnesemic hypoparathyroidism associated with long-term use
- Vitamin B12 deficiency has been found with use of PPIs for 12 or more months
Clearly there are valid medical indications for prescribing and continuing the use of PPIs including duodenal ulcer, gastric ulcer, gastritis and duodenitis, gastrojejunal ulcer, peptic ulcer, ulcer of esophagus, Barretts esophagus, dyspepsia, esophageal reflux, stricture and stenosis of esophagus, and active upper gastrointestinal bleeding. Some of these are time-limited and we should make sure we weigh the risks and the benefits when we use these medications.
We will be starting an initiative for the more appropriate use of acid suppression therapy and appreciate your support.