2016-04-19 13:30:18 UTC

How to Talk with Patients about PPIs and Chronic Kidney Disease

April 20, 2016

A new study draws connections between the use of PPIs and the development of kidney disease.

A recent study published in the Journal of the American Society of Nephrology (JASN), “Proton Pump Inhibitors and Risk of Incident CKD and Progression to ESRD,” has raised questions among patients and health-care professionals. Here are some notes on interpreting the study, what points are the most relevant and how to talk with patients.

Interpretation

The study, from St. Louis, MO, used data from the Department of Veterans Affairs national databases and builds upon earlier studies that have demonstrated an increased association of PPI use and the development of renal insufficiency.

This study is a retrospective analysis that compares the risk of developing incident chronic kidney disease (CDK), chronic kidney disease progression and end stage renal disease (ESRD) in new users of PPIs and H2 antagonists.

Since the findings are retrospective, it is difficult or impossible to adequately adjust for baseline differences between PPI users and non-users, or for differences arising during the follow-up period, such as hospitalizations. However, the study raises concern that chronic PPI use may contribute to kidney disease.

Gastroenterologists should continue to prescribe PPIs when the benefits of PPIs exceed the risks. In all patients, the need for PPIs should be periodically reassessed and gastroenterologists should be familiar with PPI tapering strategies.

Talking to Your Patients

  1. Inform patients that, while this study does raise some concern about long-term PPI use and the potential contributions to kidney disease, the study does not show that PPI use causes kidney disease. No decisions should be made in haste as a reaction to this study.
  2. Reassure patients that the benefits of using PPIs often outweigh the possible risks. Let them know that you prescribed a PPI for a clear-cut indication, in the lowest possible dose, and for an appropriate period of time (lowest dose, shortest time). This advice echoes that offered by AGA and ABIM in the Choosing Wisely campaign.
  3. Consider various options for how your patient would like to move forward. Some patients may wish to consider trying an H2 antagonist instead of a PPI.
  4. Recommend that patients also consider lifestyle modifications that may reduce or eliminate the need for PPIs for long term use, as was concluded in the study “Lifestyle Intervention in Gastroesophageal Reflux Disease.”
  5. Keep conversation channels open with patients. Tell them that many patients require long-term use of PPIs as a highly effective therapy for many conditions. They shouldn’t stop medication without first talking with you about the risks and benefits. The need for PPIs should be periodically reassessed. Be sure to stay up-to-date on proper PPI tapering strategies.

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