PPI link to acute gastroenteritis is another reason to deprescribe

Medicines

By Michael Woodhead

28 Nov 2019

Continuous use of proton pump inhibitors is linked to an increased risk of acute gastroenteritis, particularly in older people, a French study has found.

The results add to a growing body of evidence of PPI adverse effects and support their deprescribing, say researchers in JAMA Network Open.

In their retrospective cohort study, the investigators examined the occurrence of acute gastroenteritis in 234,000 patients receiving PPI therapy and 627,000 matched patients not receiving PPI therapy during the 2015 and 2016 winter seasons.

Acute gastroenteritis was reported in 3131 patients (1.3%) receiving PPI therapy and in 4327 patients (0.7%) not receiving PPI therapy.

There was a significant association between continuous PPI use and acute gastroenteritis with a relative risk (RR) of 1.81 overall, translating to a number needed to harm of 153 patients.

The risk of age with PPI use was higher in older people, with the RR of 1.66 among those aged 45 to 64 years, 2.19 among those aged 65 to 74 years, and 1.98 among those aged 75 years and older.

Younger age groups, (under 45 years of age) showed no significant increased risk of acute gastroenteritis.

A similar association was found between the continuous use of H2 receptor antagonists and acute gastroenteritis occurrence

The study authors said an increased risk of enteric infections with PPIs was already seen with pathogens such as C. difficile. They noted there was a plausible biological mechanism that PPIs may promote overgrowth of gut flora by reducing the secretion of hydrochloric acid, thus increasing bacterial translocation, affecting the gastrointestinal microbiome, and weakening the immune system.

“One-half of continuous PPI prescriptions are inappropriate. Associations such as those reported in this study are yet another reason to reexamine unnecessary and non–evidence-based indications for PPI therapy,” they concluded.

An accompanying commentary said the message was still that long-term PPI therapy should be limited to prevention of NSAID drug–induced ulcers, severe oesophagitis, Barrett oesophagus, idiopathic chronic ulcer, refractory gastroesophageal reflux disease, pathologic hypersecretory conditions, and certain patients with a history of gastrointestinal ulcer with bleeding.

“Potential candidates for deprescribing include patients with a history of H. pylori infection, peptic ulcer disease, heartburn, dyspepsia, or gastroesophageal reflux disease but no present indication for antisecretory treatment,” it suggested.

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