Proton pump inhibitors (PPIs) are one of the most frequently prescribed medicines today. While, like most medications, they can certainly have a positive impact in some cases, its been suggested that PPI’s are prescribed without a clear indication for their use in up to 70% of cases, and as we often point out – long term drug usage without a clear effect can be a real risk. Today, let’s look at PPI’s and whether you should be taking them.
What are PPI’s?
Proton pump inhibitors, or PPIs were introduced in the 1980s and rapidly became some of the bestselling medicines of all time. They work by preventing the body from producing gastric acid and are therefore effective for treating a number of gastrointestinal conditions, such as peptic ulceration, oesophagitis and gastro-oesophageal reflux[1],[2]. Research has also suggested that they are an effective preventative measure against non-steroidal anti-inflammatory drug (NSAID) induced upper gastrointestinal injury[3]. In each of the cases however, the research supports only short-term use, with few conditions ever requiring use exceeding 4 to 8 weeks.
PPI’s have an additional benefit – they’re cheap and cost effective. Annually, the NHS spends more than £100m on PPI’s[4], which begs the question – are we over prescribing?
Are we hooked on PPI’s?
Like many common medications, such as NSAID’s, Paracetamol or Aspirin, studies consistently find that PPIs are overprescribed globally in both primary and secondary care. Their prevalence continues to increase: in Australia, for example prescriptions rose by 1,318% over one decade (1996–2006)[5]. While some of this growth is the legitimate result of either PPI usage as part of a preventative treatment plan alongside other medications, or simply a consequence of more people being treated within the health system – much of the increase in use comes from over prescription. This trend may only get worse in the near future, as esomeprazole, a popular PPI, has now been approved for general sale, and pantoprazole as an over-the-counter medicine, may further drive consumer use here in the UK.
Some studies have tried to explore the appropriateness of PPI prescriptions, with some shocking results. In one study of older patients in Italy, 30% were taking a PPI with no clear indication, although a further 11% of this cohort possessed a recognised indication and were not on treatment (that is to say that PPIs were actually underprescribed)[6]. A study of 124,133 first-time adult users from Denmark found that only one third met criteria for potential long-term use[7]. In the same group, only 4% of pre-existing long-term users (defined as more than 60 daily doses over a six-month period) had a diagnosis that merited long-term management[8].
Clearly, PPI’s are being prescribed, or even under prescribed without due consideration – in large part this is due to the popular perception that PPI usage is risk free, although as we will explain in a moment, this isn’t necessarily true.
PPI’s aren’t just an easy medication to prescribe in the first instance however – many get “stuck” using them long term, as getting off them can be tricky. After a period of use exceeding a few weeks, acid hypersecretion (the overproduction of stomach acid) can often occur. This causes rebound symptoms, and frequently establishes a vicious cycle of drug re-prescription and long-term continuation.
Are PPI’s safe?
Like most medications, PPI’s might be an appropriate short-term step – we certainly don’t suggest you stop taking anything which your doctor has prescribed for you immediately – but as is usually the case, long term usage can come with significant problems. Over the past decade, many adverse effects of PPI therapy have been identified, so long term users should at least discuss with their healthcare provider if there might be another option.
The most widely studied of the negative effects is the particularly nasty Clostridium difficile infection. A meta-analysis of 23 studies, involving almost 300,000 patients, identified a 65% increase in the relative risk of C. difficile-associated diarrhoea[9]. There are suggestions that PPIs also increase risks of Campylobacter and Salmonella gastroenteritis[10], and two studies demonstrate alterations in the gut microbiome[11].
Perhaps a less obvious possible complication, studies have also shown that long term PPI use correlates with an increased fracture risk – an issue especially worth considering for older individuals[12].
Finally, increased rates of chronic kidney disease and myocardial infarction have been reported among PPI users. In one study of 173,321 patients, the hazard ratio of developing chronic renal impairment was 1.22, rising with increasing duration of exposure[13]. In a further data-mining exercise examining records from 2.9 million patients, PPIs were associated with a 1.16-fold risk of myocardial infarction, and a 2-fold increased risk of cardiovascular mortality[14].
Should I avoid PPI’s?
As a chiropractic clinic, we promote good health through natural, drug free approaches wherever possible. In some cases, PPI’s will be the right medication for the job, but where this is the case do be sure to discuss with your doctor how long you should take them for, and when you’ll taper off. Perhaps more importantly however, there are stops you can take to avoid a situation demanding PPI’s in the first instance.
As we mentioned at the start, PPI’s are often used as a protective medicine, associated with long term use of NSAIDS – and these are exactly the kind of medications which regular chiropractic care can assist you to exclude from your daily routine. If you are stuck taking PPI’s alongside a medication designed to treat pain, or inflammation, why not pop in today and see if chiropractic could offer a way to ditch both sets of medication, once and for all!
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[2] Ford AC & Moayyedi P. Dyspepsia. The BMJ 2013;347:f5059. doi: 10.1136/bmj.f5059
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[8] Haastrup PF, Paulsen MS, Christensen RD et al. Medical and non-medical predictors of initiating long-term use of proton pump inhibitors: a nationwide cohort study of first-time users during a 10-year period. Aliment Pharmacol Ther 2016;44:78–87. doi: 10.1111/
[9] Janarthanan S, Ditah I, Adler DG et al. Clostridium difficile-associated diarrhea and proton pump inhibitor therapy: a meta-analysis. Am J Gastroenterol 2012;107:1001–1010. doi: 10.1038/ajg.2012.179
[10] Leonard J, Marshall JK & Moayyedi P. Systematic review of the risk of enteric infection in patients taking acid suppression. Am J Gastroenterol 2007;102:2047–2056. doi: 10.1111/j.1572-0241.2007.01275.x
[11] Imhann F, Bonder MJ, Vich Vila A et al. Proton pump inhibitors affect the gut microbiome. Gut 2016;65:740–748. doi: 10.1136/gutjnl-2015-310376
[12] Khalili H, Huang ES, Jacobson BC et al. Use of proton pump inhibitors and risk of hip fracture in relation to dietary and lifestyle factors: a prospective cohort study. The BMJ 2012;344:e372. doi: 10.1136/bmj.e372
[13] Xie Y, Bowe B, Li T et al. Proton pump inhibitors and risk of incident CKD and progression to ESRD. J Am Soc Nephrol 2016. doi: 10.1681/ASN.2015121377
[14] Shah NH, LePendu P, Bauer-Mehren A et al. Proton pump inhibitor usage and the risk of myocardial infarction in the general population. PLoS One 2015;10:e0124653. doi: 10.1371/journal.pone.0124653
