PPI Use Linked to Increased Pneumonia, C Dificile, and Osteoporotic Fractures

SFHP has observed a dramatic increase in the use of PPIs over the last few years, despite data showing adverse clinical outcomes with short- and long-term PPI use (see citations below):

• increased risk of pneumonia in the elderly
• increased incidence of c difficile disease
• increased risk of osteoporotic fractures
• interference with clopidogrel

Since a recent study showed that brief PPI use produces acid hypersecretion and rebound GERD symptoms in healthy volunteers with no GI disease, patients will likely need tapering regimens of up to three months.  The following interventions can decrease the risk of adverse outcomes:

• Use H2 blockers, calcium carbonate, and lifestyle modifications instead of PPIs, unless patients have a clear diagnosis of peptic ulcer disease
   
• Only prescribe PPIs for brief periods, and then return to H2 blockers or lifestyle changes
   
• Ensure patients who are put on PPIs while inpatients for prophylaxis are not continued indefinitely upon discharge
   
• Give patients a trial off of PPIs, with a structured tapering program:
  
  • Use alternating H2 blockers with PPIs (with PPI q 2 days, then q 3 days, etc
  •  Plan for 3 month wean, as symptoms from hypersecretion have been observed for three or more month
  • Use H2 blockers for a period of 1-3 months after discontinuing PPIs
  • Coach patients about reasonable expectations:  it is normal to experience GERD symptoms for three or more months after discontinuation as their body re-equilibrates, and dietary and lifestyle modifications, with H2 blockers or calcium carbonate as needed, can help them cope with the symptoms.

Proton pump inhibitor facts:

Long-term PPI use among SFHP members has steadily increased over time.

• Since 2007, the number of patients (per 1000 members) using Prilosec OTC, pantoprazole, and famotidine has more than doubled (for each drug), while use of other anti-ulcer agents has remained stable, demonstrating that the number of new users continues to increase. 

It is very common for patients to be on PPIs, even when they are not needed:

• Continuation from hospitalization, when placed on PPIs for ulcer prophylaxis 
   
• Treatment for nonspecific dyspepsia, then experiencing rebound symptoms when PPIs are stopped (since healthy volunteers have symptoms after stopping PPIs, many patients are convinced their rebound symptoms are proof they "need" PPIs whenever they try to stop).

SFHP paid over $160,000 last year in PPI costs.  Even though Prilosec OTC only costs 64 cents per tablet, it adds up when members take PPIs indefinitely.

• Acid-suppressing gastrointestinal agents and drug-drug interaction with clopidogrel
  Most acid-suppressants block an important liver enzyme, CYP2C19.  Blocking this enzyme can decrease the effectiveness of clopidogrel.  Make sure your patients who are on clopidogrel and need acid-suppression are on a SFHP-preferred agent that does not block CYP2C19 -- ranitidine, famotidine or pantoprazole.
  
• Duration of therapy for gastroesophageal reflux disease (GERD)
  When was the last time you gave your patients with GERD a trial off acid suppression therapy?  Avoid unnecessary medications and consider a trial off treatment.  If your patient with GERD is able to go three months or longer without a recurrence of symptoms, then consider using short-term acute treatment rather than long-term maintenance therapy.

Regarding risk of Clopidogrel and PPIS:
http://www.ncbi.nlm.nih.gov/pubmed/19731021?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

Regarding risk of PPIs and osteoporosis:
http://www.ncbi.nlm.nih.gov/pubmed/19674854?ordinalpos=8&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

Regarding rebound symptoms in healthy volunteers:
http://www.ncbi.nlm.nih.gov/pubmed/19362552?dopt=Abstract

Regarding PPIs and overutilization:
http://www.ncbi.nlm.nih.gov/pubmed/19262544?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

Regarding PPIs and pneumonia
http://www.ncbi.nlm.nih.gov/pubmed/17502537?ordinalpos=10&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum