PPIs - time to rethink our use?

The Buzz: Benefits of PPIs may not outweigh the risks for many patients
Citation: Arch Int Med 170(9) May 10, 2010
Summary: The May 10, 2010 issue of Archives of Internal Medicine is centered around the theme "Less is more", and a number of articles focus on PPI use. "A staggering 113.4 million prescriptions for PPIs are filled each year, making this classs of drugs, at $13.9 billion in sales, the third highest seller in the United States," one editor points out. He goes on to suggest that "between 53% and 69% of PPI prescriptions are for inappropriate indications." Other highlights from this issue include:

• Evidence-based indications for PPIs include errosive and ulcerative esophagitis, Barrett esophagus, Zollinger-Ellison syndrome, severe GERD, short-term treatment of ulcers, eradication of H. Plyori, and ulcer prevention with NSAID use.
• A study of 130,487 postmenopausal women with 7.8 years of follow-up found PPIs were associated with and increased rate of spine, lower arm, and total fractures. (HR = 1.25)
• A study of more than 1,000,000 hospital discharges found daily PPI use contributed to a 73% increased risk of C difficile infection
• PPIs also significantly increase the risk of hospital and community-acquired pneumonia

While this seems very convincing, those of us on the front-lines deal with the reality that 25% of adults report dyspepsia and PPIs do help. Moreover, PPI use fits our current medical model of naming symptoms and treating them with a pill. The authors suggest we should instead offer other treatments than PPIs for functional dyspepsia, prescribe short courses of PPIs (after disclosure of possible risks and benefits), and consider a trial of discontinuing PPIs in asymptomatic patients.

Commentary: Improving health care often means doing less, and this is one example where we may be helping our patients by steering them away from PPIs when not indicated.
By: Spencer Blackman MD