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AGA Issues 10 Best Practice Recommendations for Long-term PPI Use
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In the AGA’s newly released clinical practice update on long-term use of proton pump inhibitors, experts recommended that health care providers should weigh the risks and benefits of these medications before prescribing them to patients. They further emphasized that the benefits likely outweigh the risks when PPIs are prescribed appropriately.
“Despite the long list of potential adverse effects associated with PPI therapy,” including kidney disease, dementia, myocardial infarction, small intestinal bacterial overgrowth, spontaneous bacterial peritonitis, Clostridium difficile infection, pneumonia, micronutrient deficiencies and gastrointestinal malignancies, “the quality of evidence underlying these associations is consistently low to very low,” Daniel E. Freedberg, MD, of the division of digestive and liver diseases at Columbia University Medical Center, and colleagues wrote. “In addition, the magnitudes of absolute risk increase for individual patients are modest, particularly at once daily dosing. We recommend that patients take long-term PPIs for complicated GERD, uncomplicated GERD with objective evidence of excess acid, Barrett’s esophagus with GERD symptoms, and NSAID bleeding prophylaxis if high-risk. For patients who do not fall into these categories, the lack of solid evidence means that the risk–benefit equation is less clear.”
Daniel E. Freedberg
To assess the risks associated with long-term PPI use in GERD, Barrett’s esophagus and NSAID bleeding prophylaxis, Freedberg and colleagues reviewed relevant medical literature published through July 2016, and condensed their findings into 10 best practice recommendations:
1. Patients with GERD and acid-related complications like erosive esophagitis or peptic stricture should take PPIs for short-term healing, for maintaining healing and for long-term control of symptoms;
2. Patients with uncomplicated GERD for whom PPIs are effective in the short-term should try to stop or reduce PPI use, and if they cannot, they should consider ambulatory esophageal pH/impedance monitoring to help determine if they have GERD or a functional syndrome before taking long-term PPIs;
3. Patients with Barrett’s esophagus and symptomatic GERD should be treated with long-term PPI therapy;
4. Patients with Barrett’s esophagus who are asymptomatic should consider long-term PPI therapy;
5. Patients with an increased risk for ulcer-related bleeding from NSAIDs who continue to take NSAIDs should also take PPIs;
6. Long-term PPI dose should be evaluated periodically and the lowest effective dose should be prescribed;
7. Routine probiotics should not be used to prevent infection in long-term PPI users, due to lack of evidence;
8. Calcium, vitamin B12 or magnesium intake should not be routinely above recommended dietary allowance in long-term PPI users, due to lack of evidence;
9. Bone mineral density, serum creatinine, magnesium or vitamin B12 should not be routinely screened or monitored in long-term PPI users, due to lack of evidence; and
10. PPI formulations should not be chosen based on potential risks, due to lack of evidence.
The benefits of PPIs likely outweigh the risks as long as they are prescribed appropriately, but when prescribed inappropriately, “modest risks become important because there is no potential benefit,” Freedberg and colleagues concluded. “There is currently insufficient evidence to recommend specific strategies for mitigating PPI adverse effects,” they added. – by Adam Leitenberger
Disclosures: The researchers report no relevant financial disclosures.
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