2017-07-06 13:29:56 UTC

A Guide to Conversations About the Latest PPI Research Results

July 6, 2017

New research indicates long-term PPI use may be associated with a higher risk of death.

A recent study published in BMJ, “Risk of death among users of Proton Pump Inhibitors: a longitudinal observational cohort study of United States veterans,” is getting significant media coverage and potentially causing alarm and questions among patients who use this common class of drugs. Below are notes on interpreting the study, what points are the most relevant and how to effectively communicate the data with patients. These comments are not an endorsement of this study or its findings, but rather offered as a guide to enhance conversations with patients and colleagues.

Interpretation

Amidst all the data surrounding proton pump inhibitors (PPI) use and increased risk of various adverse events, this study looked to examine the association of PPI use and all-cause mortality.

This study used administrative data from the U.S. Department of Veterans Affairs. A large primary cohort of new users of acid suppression therapy was followed for a median of 5.71 years. The primary cohort looked at patients who received a prescription for H2 blockers or PPIs, while two secondary cohorts sought to examine the association of PPI use and death in PPI vs. non-PPI users and PPI vs. non-users of acid suppression therapy. The cohorts were mostly white, older, male U.S. veterans, which could potentially limit generalizability. The primary outcome was time of death, and data on cause of death was not collected. 

Significant association was found between PPI use and risk of all-cause mortality, using various analytical approaches and all cohorts. Overall, the risk was increased among PPI use vs. H2 blockers and non-users of acid suppression therapy. From this study “the results suggest excess risk of death among PPI users; risk of death was increased among those with no documented medical indications for PPI use and with prolonged duration of use.” While a large data set was used, the causes of death were not reported. Nevertheless, the study is receiving a lot of attention and clinicians can expect to hear from many interested and worried patients and colleagues.

Talking to Your Patients

  1. Educate patients on the fact that new research has been released, and more researched continues to be done, on PPI use. Reassure patients that while this study may seem scary, it still indicates that those who have a diagnosed condition that is helped by PPIs should stay on them, as benefits can outweigh those risks. 
  2. Ensure that patients who have a medical need for PPIs don’t make any changes to their medication without discussing it with you (or another health-care professional). If they have concerns, discuss the reason for the prescription, the dose and the length of time you have suggested them to be used. This advice echoes that offered by AGA and ABIM in the Choosing Wisely campaign. 
  3. Present various options to your patient on how they would like to move forward. Adherence is key, so making sure they are comfortable with their medication is of the utmost importance. Some patients may wish to consider trying an H2 antagonist instead of a PPI. 
  4. Keep up with patient communication and perhaps recommend patients to also consider life-style 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. Stay current on all PPI research. The need for PPIs should be periodically reassessed. Be sure to stay up-to-date on proper PPI tapering strategies.

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