Case–control study: Proton pump inhibitor use is a major risk factor for hepatic encephalopathy after TIPS

Abstract

Summary Background In cirrhotic patients, hepatic encephalopathy after transjugular intrahepatic portosystemic shunt (post‐TIPS HE) is common. Measures that reduce the severity of post‐TIPS HE are limited. Though recent data suggest an association between PPI use and HE, the risk in post‐TIPS HE is not well understood. Aims Examine the risk of post‐TIPS HE associated with differing classes of medications, including proton pump inhibitors (PPI). Methods Between 2012 and 2019, we collected data on known risk factors for post‐TIPS HE as well as medications used. Subjects were classified according to the development of overt hepatic encephalopathy requiring admission. Results In our cohort, admission after TIPS was common, with an average of 7.84 admissions in the post‐TIPS HE group versus 3.76 in the no HE group (P = 0.028). Consistent with previous studies, we found that MELD, grade of encephalopathy, and lower portosystemic gradient were associated with the development of post‐TIPS HE. PPI use prior to TIPS was highly associated with post‐TIPS HE (RR: 4.89, 95% CI: 1.91‐12.50). The risk of post‐TIPS HE was highest 1‐4 weeks post‐procedure but persisted for up to one year after TIPS. Other classes of acid‐suppressive medications, such as histamine receptor blockers (RR: 0.357, 0.154‐0.824) and sucralfate (RR: 0.123, 0.016‐0.924) did not demonstrate this association. Conclusions PPI use is a strong risk factor for the development of post‐TIPS HE. Clinicians should consider the risks and benefits of PPIs in cirrhotic patients undergoing TIPS. Further studies are needed to demonstrate the benefit of discontinuation of PPI, or switching to alternatives.