So what can be done for the other patients? Visit a gastroenterologist, says Rubenstein, who is also a research scientist at the Veterans Affairs Center of Excellence for Clinical Management Research.
One potential problem is that patients may have self-diagnosed without ever seeing a gastroenterologist and purchased a PPI over the counter.
Additional testing, such as an upper endoscopy, may also be needed. Another test is reflux monitoring. Any suspicious looking fundic gland polyps i. Image courtesy of R. Pouw and A. Antiplatelet therapy is associated with an increased risk of gastrointestinal bleeding and studies have demonstrated that concomitant use of a PPI significantly reduces this risk.
On the basis of in vitro studies, it has been suggested that the antiplatelet effect of clopidogrel is reduced when it is used in combination with different PPIs.
However, based on the outcomes of observational studies and one randomized study, little evidence exists for any clinically relevant interaction between clopidogrel and PPIs.
Rebound acid hypersecretion occurs after PPI therapy is stopped. This effect is most obvious in patients who have used PPIs for at least 2 months, and a related increase of symptoms is often observed within 2 weeks of PPI treatment being withdrawn.
For certain tests, it is important to be aware that PPIs may influence the results. First, in patients suspected of having GORD who are scheduled for ambulatory pH-monitoring, which aims to determine the presence of abnormal oesophageal acid exposure, reflux frequency and symptom association with reflux episodes, we believe PPIs should be stopped 7 days in advance.
Performing pH-monitoring combined with impedance in patients who have persistent reflux symptoms and previously documented GORD on a PPI, may be useful to evaluate PPI efficacy, adherence and association of complaints with non-acidic reflux.
Second, PPIs have a suppressing effect on H. This holds for the stool antigen test, urea breath test, rapid urease test, histology and culture; with the exception of serology. For these tests, it is advised to stop PPI therapy at least 2 weeks prior to testing to allow H. Third, in patients suspected of having a gastrinoma, it is important to realize that PPIs may influence test results when measuring gastrin and chromografin A levels.
However, since withdrawal of PPIs in patients with possible Zollinger—Ellison syndrome can lead to serious complications and stopping PPI is not always necessary, the decision to stop should be made on an individual basis.
The general advice for patients on a PPI who need to stop their medication for 1 or 2 weeks, is to temporarily switch to H 2 antagonists or antacids.
Roos Pouw is a registrar in gastroenterology and hepatology at the Academic Medical Center, Amsterdam, the Netherlands. Her clinical and research interests are focused on endoscopic detection and treatment of early neoplasia of the upper gastrointestinal tract. His particular research and clinical interests include benign oesophageal disorders, mainly achalasia, reflux disease and eosinophilic esophagitis. Pouw and Albert J. Bredenoord Download as PDF. Conflicts of interest: The authors declare there are no conflicts of interest.
Published online: 27 April, Prescribing a PPI without providing adequate instructions for their use. Withholding PPI treatment because of a fear of complications. Not taking hypomagnesaemia seriously in patients who are taking a PPI. Failing to prescribe a PPI to reduce the risk of gastrointestinal bleeding in high-risk patients on anticoagulation therapy.
Not warning the patient that rebound symptoms can occur after stopping PPIs. About the Authors. Your proton pump inhibitor briefing. Guidelines on eosinophilic esophagitis: evidence-based statements and recommendations for diagnosis and management in children and adults. However, in each practice population there will be some patients for whom it is appropriate to reduce the dose of the PPI they are prescribed, e.
For patients taking PPIs long-term the need for ongoing treatment should be reassessed at every consultation. There is no clear evidence as to what the best regimen for withdrawing PPI treatment is, but in general, downward dose titration should be considered when symptoms are under control.
The patient responds to treatment and their symptoms resolve. The dose is then reduced to 10 mg, daily, for two weeks, and then treatment is stopped. This should return to normal within two weeks. The symptoms caused by rebound acid secretion, e. The possibility of rebound acid secretion should be discussed with patients so they can be prepared for this when withdrawing from PPI treatment.
Medicines that contain both an antacid and an anti-foaming agent, e. Mylanta P oral liquid, Acidex oral liquid, Gaviscon Double Strength tablets are likely to be the most effective treatment for rebound acid secretion. Aluminium hydroxide tablets can also be effective. The rate of adverse effects associated with PPI treatment is relatively low. However, given that each practice is likely to have many patients taking PPIs, clinicians need to be aware of the potential risks.
These risks should be discussed with patients, and the need for periodic monitoring considered in those at increased risk. All three subsidised PPIs available in New Zealand can cause headache and gastrointestinal adverse effects, e. Less frequently, PPI use is associated with dry mouth, peripheral oedema, dizziness, sleep disturbances, fatigue, paraesthesia, arthalgia, myalgia, rash, pruritus and interstitial nephritis.
PPIs are not known to be associated with an increased risk of foetal malformations in humans Pregnancy Risk Category B3. A reasonable approach for pregnant women who require acid suppressive medication is to trial antacids e. Higher doses of PPIs should be avoided in patients with moderate to severe liver disease because decreased metabolism may cause the medicine to accumulate see NZF for details. Gastric acid suppression with PPIs increases the risk of infection with gastrointestinal or respiratory pathogens, although the absolute risk to most patients remains low.
This allows viable pathogens to travel up or down the gastrointestinal tract and also colonise the lower airways. Where possible, consider delaying the initiation of PPIs in patients with an increased risk of infection, e.
In a meta-analysis of 12 studies involving almost 3 patients, it was found that acid-suppressing treatment increased the risk of C. This risk was increased 1. In another study of over people, it was found that PPI use was associated with an increased risk of pneumonia, and the risk increased with increasing dose of PPI.
Acid in the gut increases the solubility of elements, e. It has therefore been suggested that gastric acid suppression may decrease absorption of some nutrients and lead to an increased prevalence of conditions related to malabsorption. However, this association is controversial. In most cases, patients can be reassured that a balanced diet, including essential elements and minerals e.
Long-term PPI use has been associated with a small increase in fracture risk. An increased risk of osteoporosis should be considered in post-menopausal females who are taking PPIs long-term, especially if they have other risk factors, e. Severe hypomagnesaemia has been associated with the use of PPIs , in a limited number of patients, which resolved when PPI treatment was withdrawn.
Omeprazole, 20 — 40 mg per day, was the dosage most frequently associated with these deficiencies. Patients with a history of excessive alcohol use, who are taking a PPI, have an increased risk of developing hypomagnesaemia due to the additive effects of chronic ethanol exposure on metabolic function. The use of diuretics, ciclosporin or aminoglycosides with PPIs increases the risk of hypomagnesaemia occurring. Symptoms of hypomagnesaemia are non-specific and may include muscle cramps, weakness, irritability or confusion.
Routine testing of magnesium levels in patients taking PPIs is generally not recommended. However, if a patient has been taking a PPI long-term and they present with unexplained symptoms that are consistent with hypomagnesaemia, consider requesting a serum magnesium level.
Increased dietary intake of magnesium rich foods, e. For some patients the PPI will need to be stopped; if the indication for using the PPI is strong, a re-challenge while monitoring magnesium can be undertaken. Vitamin B12 deficiency has been associated with the use of PPIs in older patients. Hyponatraemia has been associated with the use of PPIs in a very small number of patients. The patient should be referred to a Nephrologist for assessment. PPIs help to decrease stomach acid over a four to week period.
This amount of time allows for proper healing of the esophageal tissue. It may take longer for a PPI to ease your symptoms than an H2 receptor blocker, which usually starts reducing stomach acid within one hour. However, symptom relief from PPIs will generally last longer.
It contains a combination of esomeprazole and naproxen. You could possibly have a Helicobacter pylori H. This type of infection requires more complex treatment. This makes it hard to distinguish between the two conditions. Symptoms of an H. If your doctor suspects you have an H. Then they will determine an effective treatment plan.
PPIs have traditionally been considered to be safe and well-tolerated medications. However, research now suggests that certain risks may be involved with long-term use of these drugs.
A recent study found that people who use PPIs long-term have less diversity in their gut bacteria. This lack of diversity puts them at an increased risk for infections, bone fractures, and vitamin and mineral deficiencies. Your gut contains trillions of bacteria. This can result in illness. Additionally, the U.
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