Bini Susan Isaac
Clinical Pharmacist, Kauvery Hospital, Salem, India
*Correspondence: +91 9497052726 ;clinicalpharma.khs@kauvery.in
Abstract
Proton Pump Inhibitors (PPIs) block the acid-producing enzyme system in the stomach wall and prevent acid production in the stomach. Lack of acid in the stomach prevents ulcer formation, promotes healing of existing ulcers in the esophagus, stomach, and duodenum and provides symptom relief. PPIs differ in how they are metabolized by the body, how they interact with other medications, and the length of time they are active in the body. However, there is no evidence that one PPI is more effective than another at treating any of the approved indications [1].
Keywords: Hydrogen-potassium ATPase pump, Zollinger-Ellison Syndrome, Gastroesophageal reflux disease, non-erosive gastroesophageal reflux disease.
Background
Proton pump inhibitors (PPIs) effectively block gastric acid secretion by irreversibly binding to and inhibiting the hydrogen-potassium ATPase pump that resides on the luminal surface of the parietal cell membrane [2].
Indications
They are often the first-line agents amongst gastro enterologists for the following
- Esophagitis
- Non-erosive reflux disease
- Peptic ulcer disease
- Prevention of nonsteroidal anti-inflammatory drug-induced ulcers
- Zollinger-Ellison Syndrome
- Part of the triple therapy regimen for Helicobacter pylori infections
The FDA has approved the following PPIs as of 2015:
- Omeprazole
- Esomeprazole
- Lansoprazole
- Dexlansoprazole
- Pantoprazole
- Rabeprazole
Inhibiting gastric acid secretion
PPIs are successfully used for the short-term treatment of gastroesophageal reflux disease (GERD) and the long-term prevention of recurrence.
On-demand PPI treatment may be used to prevent recurrence in patients with non-erosive gastroesophageal reflux disease (NERD).
In patients with erosive reflux esophagitis, daily PPI intake is more effective in preventing recurrence after healing. However, half of the dose initially used for acute treatment may be sufficient for long-term prevention.
Whether PPIs can delay the progression of intestinal metaplasia of the esophagus (Barrett’s esophagus) has not been conclusively proven. PPIs are effective and superior to histamine-2 receptor antagonists (H2 blockers, H2RAs)—in the healing of gastric ulcer and duodenal ulcer, regardless whether the ulcer is caused by NSAID use or Helicobacter pylori.
PPIs are the first-line treatment for secondary prevention of gastroduodenal lesions associated with the use of NSAIDs, including aspirin (acetylsalicylic acid, ASA), and for the acute treatment of ulcer bleeding and the prevention of recurrent ulcer bleeding after successful primary endoscopic hemostasis.
Due to the lack of large-scale studies, it is not possible to draw conclusions about the role of PPIs for primary prevention in patients treated with NSAIDs, with regard to the number needed to treat (NNT) and the number needed to harm (NNH). Consequently, PPIs are not approved for this indication.
However, some evidence supporting the use of PPIs for primary prevention is available: PPIs reduce the risk of developing NSAID-related ulcers.
Furthermore, they lower the bleeding risk associated with dual antiplatelet therapy with low-dose aspirin and clopidogrel.
PPIs are a component of almost all of today’s antibiotic combination regimens for the eradication of H. pylori infection.
In addition, PPIs are also used temporarily after esophageal variceal ligation for the prevention of bleeding from ligation-related ulcers. However, the evidence level for this treatment approach is not high [3].
Conclusion
Many patients take PPIs, and it is crucial to recognize when the indication for use no longer exists or when they are not working effectively for a patient. For example, approximately 50% of patients taking PPIs for non-erosive GERD do not have their symptoms eradicated. In these cases, it becomes important to communicate to the patient that an increase in the PPI dosage may be a viable option. However, given the number of potential side-effects associated with long-term PPI, it is reasonable for clinicians to prescribe the lowest effective dose for the shortest period possible and maintain an adequate level of rapport with patients to adjust according to their needs.
This is why an inter professional team approach to using PPIs is necessary. Clinicians prescribe the medications, but nursing staff should be able to answer any questions about the drug, including how to watch for potential adverse effects. Pharmacists will check for interactions and reinforce counseling points from the nurse. All team members need to contact the prescriber in the event of an adverse event or therapeutic insufficiency. This will result in optimal patient outcomes when using this drug class [4].
References
[1]Proton Pump Inhibitors: Use in Adults- cims october 2015
[2]Wolfe MM, et al. Acid suppression: optimizing therapy for gastroduodenal ulcer healing, gastroesophageal reflux disease, and stress-related erosive syndrome. Gastroenterology 2000;118:S9.
[3]Edwards SJ, et al. Systematic review: standard- and double-dose proton pump inhibitors for the healing of severe erosive oesophagitis-a mixed treatment comparison of randomized controlled trials. Aliment Pharmacol Ther. 2009;30:547–56.
[4]Spechler SJ. Proton Pump Inhibitors: What the Internist Needs to Know. Med Clin North Am. 2019;103(1):1-14.
Dr. Bini Susan Isaac
Clinical Pharmacist