Long Term Acid Suppressant Medications (ppi’s): Concerns and Care
Maintenance antisecretory acid therapy (PPI’s) are used in many patients,
particularly those with gastroesophageal reflux disease(GERD). With the long-term use of any medication, drug safety becomes an important issue. Acid (HCl) is normally secreted into the gastric lumen, where it serves to both digest dietary protein and maintain a sterile environment by removing ingested bacterias. Proton pump inhibitors (PPIs) are strong acid suppressants, and thus long term usage has raised several issues which shall be discussed in this article.
The three main concerns regarding the long-term usage of proton pump inhibitors (PPIs) include :
Risk of infectious complications – including Pneumonias, Cl difficile diarrhoeas
Malabsorption of Iron, Vitamin B12, Magnesium and Metabolic bone disease
Hypergastrinemia, Gastric carcinoids and Atrophic Gastritis
Other concerns include acute interstitial nephritis (kidney disease) and drug interactions particularly reducing the effect of Clopidogrel, which is used in coronary stented patients to reduce the risk of stent blockage.
InfectionsA concern with any form of gastric acid inhibition is an increased risk of enteric infections since gastric acid normally protects against these infections. In addition, a reduction in gastric acid secretion permits bacteria to more easily colonize the upper gastrointestinal tract, which may predispose to pneumonia.
Clostridium difficile and other enteric infectionsThe best documented association of PPI use with enteric infections has been with C. difficile diarrhea, even in patients not exposed to antibiotics(1-7). C. difficile is an anaerobic organism that sporulates; acid-resistant spores are presumed to be the major vector of disease transmission. Three meta-analyses of observational studies have demonstrated an increased risk of C. difficile infections in patients treated with PPIs(8-10). A 2012 meta-analysis of 42 observational studies that included 313,000 patients found that PPI use was significantly associated with an increased risk of both incident and recurrent C. difficile infection(9).
The US Food and Drug Administration (FDA) has issued a safety alert encouraging providers to consider a diagnosis of C. difficile-associated disease in PPI users with persistent diarrhea(11). Given the potential risk of C. difficile infection, the FDA has also recommended that providers prescribe the lowest dose and shortest duration of PPI therapy appropriate to the condition being treated.
Associations with other enteric infections, including Campylobacter and Salmonella, have also been reported(12-15), but the risk is uncertain(16).
PneumoniaThe risk of pneumonia in PPI users may be increased due to a reduction in gastric acid secretion, permitting bacteria to more easily colonize the upper gastrointestinal tract. The increased risk has been seen with both community-acquired pneumonia (CAP) and health care associated pneumonia (HCAP)(17-19). A meta-analysis of 31 studies found that patients taking PPIs or H2 receptor antagonists (H2RAs) were at increased risk for pneumonia(20).diesel fire pump
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