Rebuilding trust in proton pump inhibitor therapy

Abstract

Introduction of proton pump inhibitor (PPI) therapy into clinical practice has revolutionized treatment approach to acid-related diseases. With its clinical success came a widespread use of PPI therapy. Subsequently, several studies found that PPIs were oftentimes overprescribed in primary care and emergency setting, likely attributed to seemingly low side-effect profile and physicians having low threshold to initiate therapy. However, now there is a growing concern over PPI side-effect profile among both patients and providers. We would like to bring more awareness to the currently available guidelines on PPI use, discuss clinical indications for PPIs and the evidence behind the reported side-effects. We hope that increased awareness of proper PPI use will make the initiation or continuation of therapy a well informed and an evidence-based decision between patient and physician. We also hope that discussing evidence behind the reported side-effect profile will help clarify the growing concerns over PPI therapy.

Key Considerations From a Health Authority Perspective When Proton Pump Inhibitors Are Used to Treat Gastroesophageal Reflux Disease (GERD) and Their Implications

“…This should be combined with compliance with counseling on lifestyle changes [ 62 ], with weight loss potentially reducing PPI doses [ 22 ]. Overall, optimal dosing of PPIs combined with lifestyle management appears to be the most effective and cost-effective approach to managing patients with GERD where lifestyle changes are insufficient [ 1 , 5 , 20 , 44 ].…”

“…With PPIs firmly established as a first-line pharmacologic treatment for patients with GERD [ 1 , 5 , 20 , 44 , 47 ], which PPI to prescribe should be based on key issues, including their effectiveness, safety, and cost-effectiveness as there can be appreciable cost variations between the different PPIs [ 55 ]. In their review, Graham and Tansel (2018) and others have concluded that all PPIs are functionally equivalent [ 55 , 78 ].…”

“…In addition to these issues, there are concerns with the long-term complications of PPI use and the potential impact on enhancing polypharmacy and associated matters. However, these concerns must be balanced against their undoubted effectiveness especially given issues with the complications of GERD as well as patients still being admitted to hospitals with stomach ulcers [ 5 , 83 ]. In addition, these issues and concerns may be less of a problem at doses of PPIs available OTC [ 74 ].…”

“…Antacids, alginates, histamine (H 2 ) receptor blockers, or proton pump inhibitors (PPIs) are typically a firstline medical treatment for patients with GERD [1,[38][39][40]. In recent years, PPIs, e.g., omeprazole, which work by covalently binding to the proton pumps that control the final step of gastric acid production, thereby decreasing it, have become the treatment of choice for patients with GERD, with a number of studies showing superiority over H 2 receptor blockers [5,38,[41][42][43][44][45][46][47][48][49]. Typically, a standard dose of a PPI provides complete relief in approximately 70 to 80% of patients with GERD within a week [1,[50][51][52][53], with limited differences in effectiveness between twice-daily and once-daily PPIs [54].…”

“…Serious complications include dysphagia and Barrett's esophagus, potentially leading to esophageal adenocarcinoma [3]. GERD is a common condition, often due to abnormalities in the lower esophageal sphincter [4,5], with a pooled global prevalence of 13.3% or more of the population reporting at least weekly symptoms with rates increasing; however, with appreciable geographical variation [1,3,[6][7][8][9][10]. Weekly prevalence rates currently range from 2.5% of the population in China up to 51.2% in Greece [6].…”