Concerns about long term acid suppressive therapy

Physicians hate acid. But,  hey, who doesn’t hate acid? It burns things. It corrodes. It’s that after-pizza punishment.

We prescribe antacid medications by the ton in this country, not because people’s stomachs have developed increased acidity, but because people in our modern society are generally overweight, like to eat large meals, and prefer fatty foods and things like alcohol, chocolate, and tobacco, all of which tend to worsen acid reflux.

Physicians like to prescribe many different types of antacids because the patients like them and there are no perceived down sides (except cost). In particular, we prefer the so-called, proton pump inhibitors (PPIs) like omeprazole (Prilosec), lansoprazole (Prevacid), esomeprazole (Nexium), pantoprazole (Protonix), and rabeprazole (Aciphex) because PPIs are the most potent inhibitors of gastric acid secretion available are very effective treatment of moderate to severe gastritis, reflux, and peptic ulcer disease. So of course, if PPIs are good enough for the serious gastric illnesses, then they must be great for just about everything else! Right?

Proton pump inhibitors are prescribed  for even the slightest bit of heart burn or dyspepsia even though there is no good evidence for the effectiveness of intermittent use of PPIs for the treatment of the occasional over-eating  syndrome or that they are better for mild conditions than over-the-counter Tums, Pepcid, or Zantac.

PPIs are also heavily used in the hospitalized patient, especially those in the ICU, where various conditions like sepsis, hypotension, hypovolemia, stress, medications, and increased intracrainal pressure are risk factors for the development of gastritis and ulcers. Often the PPI therapy follows the patient home from the hospital and continues to be prescribed long after the original need for it has been forgotten.

There have been concerns about long term acid suppressive therapy, but until recently there has not been much hard data on the risks. That has now changed with the addition of two studies appearing in the archives of internal medicine.

  • If used within 14 days of the initial infection, PPIs increased the risk of recurrent Clostridium difficile infection in hospitalized patients from 18 to 25%. Especially in patients over 80 and on antibiotics (for other infections).
  • Long term (> 7-8 years) use of PPIs was associated with about a 25% increased risk of fractures of the spine, wrist, and forearm in postmenopausal women 50-80 years old compared to only an 8% increased risk with the use of other antacids. Interestingly, there was no associated increased risk of hip fracture and there was little difference in the measured bone mineral densities of women on PPIs compared to those not on these medications.
  • Starting PPIs  within the preceding week was associated with an increased risk of developing pneumonia. This risk was not found with the use of antacids like Pepcid or Zantac.
  • There is limited data to suggest that PPI use may decrease absorption of iron, calcium, magnesium, and vitamin B12.
  • Several studies have suggested (thus far not definitively proven) that the use of PPIs decreases the effectiveness of clopidogrel (Plavix) when used to prevent a second cardiac event.

From 53 to 70% of prescriptions for PPIs are written for mild to moderate and intermittent conditions such as gastric reflux or dyspepsia for which the use of over-the-counter antacids may be safer, cheaper, and more than adequate. However, physicians must cringe at the idea of seeing a patient with mild, intermittent heart burn and simply tell them to stop eating large fatty meals and take Pepcid. If the patient takes the time to come for an expensive medical evaluation then they must get an expensive medication.

Thus it is said, the modern medical mantra: expensive is, as expensive does.

Chris Rangel is an internal medicine physician who blogs at RangelMD.com.

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