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Tuesday, May 26, 2009

Safety of Acid Reflux Drugs

Today's New York Times is reporting on a new study where patients who take proton pump inhibitors to prevent acid reflux are at higher risk for pneumonia than those who do not.

Proton Pump Inhibitors (PPIs) are amazing drugs that dramatically reduce the acid content of the stomach. This therapy has proven vital in the treatment of gastric and duodenal ulcers as well as severe cases of gastroesophageal reflux disease (GERD).

However, there have been more and more recent data regarding the safety of this medication. Not only for higher rates of pneumonia but also for cardiac reasons. There is some data that these medications have the potential to counteract the effects of plavix and there is data that patients taken both plavix and PPIs have higher rates of heart attacks than patients taking plavix without PPIs.

This raises to two important issues.
  1. All the data so far on safety of PPI and plavix is retrospective. This means that researchers go back and look to see what happens in different groups of patients. This form of research is excellent for hypothesis generating but is unable to prove causality. For tis we need prospective randomized controlled trials. I have a hunch that what researchers have seen so far is that compared with patients on just plavix, patients on both Plavix and PPIs are sicker at baseline and therefore more prone to have heart attacks because of their overall health status not because of their PPI use. In my practice, I have not seen PPIs leading to heart attacks.
  2. PPI are probably being used too much. They work so well, it is easier for a physician to just got to the most potent medication instead of trying a less potent medication to see if this works first.

Until this all plays out, I will be following the recommendations of the Society of Angiography and Intervention: "SCAI believes more research is needed on this topic. However, given the thousands of patients who receive stents each year, coupled with the significant risks demonstrated in this study, SCAI recommends the use of alternative medications for GI symptoms in patients with stents when appropriate. Other effective treatments for heartburn and ulcers include histaminergic (H2) blockers (Zantac [ranitidine, Boehringer Ingelheim], Tagamet [cimetidine, GlaxoSmithKline]) or antacids. In some patients the use of PPIs may still be warranted, based on the patient's medical problems, and should be taken at the direction of the patient's cardiologist, gastroenterologist, or primary physician."

I recommend you talk to your physician if you are on a PPI and plavix prior to stopping or changing your therapy based on this discussion.

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