Page 66 - IDF Journal 2023

IDF – Webinar Series IDF News – Spring 2023
Proton Pump Inhibitors - Long Term Safety
What Do I Tell My patients?
Dr Sarmed Sami
Proton pump inhibitors (PPIs) are highly effective in the treatment and prevention of ulcer-related and acid-related conditions. In fact, they
have altered the prevalence and natural history of these conditions. This article will address the questions around PPI safety in the long term. More importantly, what to
tell patients when they ask
us “Doctor, am I OK to take these medications long term? Are they safe?”
In order to answer these queries, first we must address the following 3 questions:
1. Does the patient need the PPIs in the first place?
2. Are there any more effective or safer alternatives to PPIs for that patient?
3. What are the data on PPI safety long term?
Figure 1. Mechanisms of heartburn despite PPIs1
Does the patient need PPIs?
Case study 1:
• 20 year old patient with persistent retrosternal burning all the time (even without eating) despite omeprazole 40 mg twice a day
• Upper GI endoscopy (OGD) normal
• Otherwise fit and well.
This is an example of a patient with no risk factors for gastroesophageal reflux disease (GORD), lack of response to PPIs, and persistent symptoms regardless of the time
or type of the meal. These 3 factors should raise suspicion that there may well be other mechanisms for the heartburn. PPIs are highly effective at suppressing acid and normalising gastric pH in 93%-99% of patients, therefore one would expect significant improvement in symptoms. Functional heartburn and other mechanisms for symptoms need to be considered (Figure 1).
In order to answer the above question, this patient needs referral to a Gastroenterologist for formal testing to exclude or confirm GORD with either 24 hour pH impedance catheter monitoring or wireless 96 hour pH capsule (BRAVO or Alpha models).
Box 1. The impact of pH testing on patients with normal OGD
Are there any alternatives to PPIs?
Case study 2:
• 50 year old man with retrosternal burning after meals and occasional acid regurgitation waking him up from sleep.
• OGD showed 2 cm hiatus hernia with grade B (moderate) GORD.
This is an example of a patient who will almost certainly benefit from long term PPIs as he has proven GORD on endoscopy with consistent symptoms. This patient also has ‘volume’ reflux with regurgitation of acid. Lifestyle modifications and PPIs may be sufficient , but if patient continues to have regurgitation symptoms, then anti-reflux surgery is likely to offer a better alternative to PPIs in this case.
Test positive = GORD = needs PPIs (benefit >risk) = high risk of complications if not treated (Barrett’s oesophagus, risk of cancer, strictures) = may be suitable for anti-reflux procedures
Test negative = GORD unlikely = consider alternative causes (figure 1) = No need for PPIs (likely risk>benefit) = low or no risk of GORD-related complications = anti-reflux procedures not needed
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