PROTON Pump Inhibitors referred to as PPIs are a very popular class of drugs because of its high efficacy to reduce acid production in gastrointestinal ailments.

According to the U.S. Pharmacists in the December 2019 edition, over 25 per cent of the world’s population is affected by some acid-related condition that translates to PPI sales worldwide of US$11B annually.

Prior to COVID-19, PPIs were ranked as the third most dispensed drug in New Zealand and in the top 10 in other parts of the world.

Proton Pump Inhibitors are indicated for GERD (gastro-esophageal reflux disease), esophagitis, peptic ulcer, gastric bleeding associated with long term use of NSAID (non-steroidal anti-inflammatory drugs) and blood thinners especially in the elderly and also as an adjunct treatment in H. Pylori infections.

In Guyana those proton pump inhibitors which are available are omeprazole (Lomac), pantoprazole, esomeprazole (Nexium) and lansoprazole. This category of drugs has been approved since 1989 by the FDA (Foods and Drugs Authority) with specific dosage and duration protocols established for its optimum use in mild, moderate and severe disease classification. However, by 2003, the FDA approved OTC (Over the Counter) versions of omeprazole and lansoprazole called Prilosec and Prevacid respectively, which are available to the general public without a prescription.

This meant that now these products were readily available to the general public who may not be equipped with the knowledge of its consequential long-term effects, side effects and contraindications due to its indiscriminate use.

Apart from the increasing pill burden and its associated unnecessary additional costs, there have been incidences from observational studies which are cause for concerns.

The Brazilian Journal of Nephrology highlighted a study done in 2017, which suggested that prolonged use of PPI causes oxidative stress which is associated with renal interstitial tubular injury, resulting in the decline of the renal function. Hence for users of PPIs, kidney health must be reviewed annually since continuous use at unrevised dosage may increase the risk of chronic kidney disease. Evidence based research to establish this hypothesis has not been done.

Generally, side effects from short term use are mild and rare but there is a growing concern of other infrequent associated effects from observational studies such as dementia, pneumonia, bone fractures and hypomagnesemia.

For enhanced bioavailability, you are advised to take PPIs on an empty stomach one hour before meals. If taken just prior meals, then the time for the drug to dissolve and absorb would have been longer when compared to the time acid production commences after chewed food reaches the stomach. Hence, food decreases its bioavailability resulting in a lower blood concentration of the PPI.

In Asians and the elderly populations, PPI tend to have an increased bioavailability. When patient charts were reviewed, some persons including elderly patients, who are high risk at diminished renal function, were not taken off PPIs or their dose was not reduced. The American Geriatric Society in 2015 cited concerns about such incidents which were included their review of inappropriate use of PPIs in the elderly.

In the American Gastroenterology Association publication, volume 162 of Clinical Practice Update dated April 2022, an expert reviewed study considered the de-prescribing of Proton Pump Inhibitors. Specialists’ consensus endorsed by the American Gastroenterological Association, reiterated that an annual review is required to evaluate the continuous indicated use is of PPI.

Several best practice advice for primary care physicians followed:
• Patients without a definitive indication for chronic use of PPI should be de-prescribed

• Twice daily dose for chronic PPI use should step down to once daily

• Do not discontinue PPI in the following patients: complicated GERD or peptic stricture

• De-prescription should not be considered for certain conditions (Barrett’s esophagus, eosinophilic esophagitis, idiopathic pulmonary fibrosis)

• Evidence based protocol instituted before de-prescribing patients with upper GI bleed

• Transient rebound effect can occur after discontinuing long term use of PI

• Consider downward dose readjustment or abrupt discontinuation when de-prescribing

• Only use lack of indication as a consideration for de-prescribing and not PPI associated adverse effect

Pharmacists are entrusted to educate patients and make de-prescribing recommendations to the primary care physicians as stated in the December 2019 issue of U.S.

Pharmacist so as to ensure appropriate use and stewardship of PPIs. The Canadian Association of Gastroenterology has alerted both physicians and patients to question the need for PPI and to choose wisely.

Endorsed and implemented protocols will target optimum treatment of various indicated conditions in a structured manner.

For further discussion, contact the pharmacist of Medicine Express PHARMACY located at 223 Camp Street, between Lamaha and New Market Streets. If you have any queries, comments or further information on the above topic kindly forward them to medicine.express@gmail.com or send them to 223 Camp Street, N/burg. Tel #225-5142.