What is the long term acid inhibitor treatment in gastroesophageal reflux disease? What are the potential problems related to long term acid inhibitor treatment in gastroesophageal reflux disease? How should these cases be followed?

Abstract

Decreased acid secretion is thought to adversely affect the absorption of calcium and increase the risk of fracture by causing a decrease in bone density. The meta-analyses of observational studies conducted with heterogeneous populations showed that the risk of any fracture (OR: 1.29, 95% CI: 1.18-1.41) and hip fracture (OR: 1.23, 95% CI: 1.11-1.36) slightly increased with PPI depending on the dose and regardless of duration; but no risk increase was detected with H2RA use (1,2).There are meta-analyses with different methodologies reporting that high gastric pH values developing due to acid inhibition increases Clostridium difficile infections by altering the intestinal microflora and in observational studies conducted with different patient populations. This risk has been reported to be higher in PPI treatment (OR: 2.15, 95% CI: 1.81-2.55) compared to H2RA (OR: 1.44, 95% CI: 1.22-1.70) (3,4).It was reported in the meta-analysis published in 2013 that bacterial overgrowth increased with the use of PPI (OR: 2.26, 95% CI: 1.24-4.2) (5). Spontaneous bacterial peritonitis that develops due to the translocation of enteric pathogens is a significant cause of mortality for cirrhotic patients. The hypothesis that the risk of spontaneous bacterial peritonitis may increase due to easy proliferation of intestinal bacteria with decreased stomach acid has been confirmed in the meta-analysis of observational studies in which the relationship with PPI was investigated (OR: 3.15, 95% CI: 2.09-4.74). On the Turk J Gastroenterol 2017; 28(Suppl 1): S57-S60What is the long term acid inhibitor treatment in gastroesophageal reflux disease? What are the potential problems related to long term acid inhibitor treatment in gastroesophageal reflux disease? How should these cases be followed? S57 ABSTRACTThe meta-analyses of observational studies (OBS) showed the risk of any fracture and hip fracture slightly increased with proton pump inhibitor (PPI) treatment depending on the dose and regardless of time. This was not observed with histamine-2 receptor antagonists (H2RA). The risk of bacterial overgrowth and spontaneous bacterial peritonitis were increased with PPI therapy, but not with H2RA. In meta-analyses of OBS, a slight increase was observed in the risk of community-acquired pneumonia (CAP) in the early stages (<1 month) of PPI use and particularly at high doses. In a five-year LOTUS study, no difference was found in vitamin B12, folic acid, vitamin D, and calcium values in terms of the initial and end of follow-up levels. No increase in the risk of premalignant gastric lesions was observed in the meta-analysis of RCTs in which PPI treatment (≥6 months) was given to Helicobacter pylori negative patients. The risk of hypomagnesemia with PPI use was increased in patients having GFR<60, using diuretics, and over 65 years of age. Quasi-experimental studies showed a reduced zinc absorption with PPI use. In the meta-analysis of OBS, long-term (>1 year) PPI use increased the risk of fundic polyps, but no risk was found in shorter use. Th...

Omeprazole vs Lansoprazole in the Management of Gastroesophageal Reflux Disease: A Systematic Literature Review

“…Omeprazole and lansoprazole are the most commonly used PPIs to treat GERD symptoms. Although there is a risk of increased bacterial growth and spontaneous bacterial peritonitis with PPI therapy [24], they have been proven safe and effective to treat nonerosive reflux disease (NERD). None of the studies in our systematic review reported any serious adverse effects, which also provides evidence that omeprazole and lansoprazole are safe and effective to use at least for a short period.…”

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“…Hatemi et al 12 concluded there is a risk for intestinal bacterial overgrowth in PPI users (level of evidence 2) and this should be considered in patients where such bacterial overgrowth might be a risk (level of evidence 5). Singh et al, 11 in turn, showed an association, but not causality, between PPI use and SIBO, and also pointed out contradictions in recent studies given the difference in types, number of participants and different diagnostic methods.…”

“…[23][24][25][26][27] This increase is more likely related to the change in pH provided by the PPI than its dose or duration of use. Hatemi et al 12 also show a higher risk for CDI (level of evidence 3a), and treatment with PPI should not be discontinued when properly indicated (level of evidence 5). Savarino et al 15 add that CDI is a possible side effect of using PPIs, as they reduce the antibacterial effect of gastric acid.…”

“…However, the authors emphasize that the pathophysiology must be clarified. Hatemi et al 12 concluded there is a slightly higher risk for CAP in PPI users with less than a month of use and at high doses (level of evidence 3a). According to observational studies, hospital pneumonia has no higher risk (level of evidence 2a).…”

Gastroesophageal reflux disease in patients with various comorbidal pathology

“…Rejuvenation of the pathology may lead to an increase in the number of complications such as Barrett's esophagus and adenocarcinoma [11] due to a longer history, which also entails a longer treatment with proton pump inhibitors (PPIs). The metaanalysis showed that long-term use of PPIs increases the risk of fractures, bacterial overgrowth and spontaneous bacterial peritonitis, community-acquired pneumonia, and decreased zinc absorption [12].…”