AIM一次整理4篇文章，高劑量PPI沒有好處，PPI和hip fracture看來無關，會增加CDI

Proton-Pump Inhibitor Dosing and Negative Consequences

Four studies about the effects of PPI therapy

The May 10, 2010, issue of Archives of Internal Medicine included four articles about proton-pump inhibitors (PPIs). Investigators evaluated use versus nonuse and higher versus lower doses for various outcomes.

Researchers conducted a meta-analysis of seven randomized trials for bleeding peptic ulcers after endoscopic treatment in which high-dose PPIs (80-mg bolus, followed by 8 mg/hour continuous infusion for 72 hours) were compared with lower-dose PPIs. No 30-day benefit for high doses was found on rate of rebleeding, need for surgical intervention, or mortality.

Investigators from the Women's Health Initiative followed more than 130,000 women without histories of hip fractures for a mean 7.8 years. In multivariate analysis, risk for hip fracture was not higher among PPI users than among nonusers, but risk for spine fractures, forearm or wrist fractures, and total fractures was significantly higher among users. Use of PPIs was associated with marginally lower bone-mineral density at the hip but not at other sites.

In a retrospective study of more than 1100 patients with Clostridium difficile infection (CDI), recurrence was significantly more common among individuals who had received PPIs than among those who had not (25% vs. 18%); 42% of these patients had received PPIs within 14 days of CDI diagnosis. A second research group evaluated more than 100,000 discharges during 5 years to determine the association between level of acid suppression (no acid suppression, daily histamine-2 receptor antagonists, daily PPI therapy, or more-than-once-daily PPI therapy) and risk for developing nosocomial CDI. Incidence of nosocomial CDI ranged from a low of 0.3% among individuals without acid-suppression exposure to 1.4% among those who received more-than-daily PPI therapy. The association remained after adjustment for confounders.

Comment: These results remind us that high-dose PPIs might not provide additional benefit relative to lower-dose PPIs for patients with bleeding peptic ulcers and that high-dose PPI use among other patient populations could have negative consequences for bone health and C. difficile infections. An editorialist notes that more than 113 million prescriptions are written each year for PPIs and that they account for more than $13 billion in sales in the U.S. PPIs have clear clinical indications; however, they are overprescribed and likely have unintended negative consequences.

— Jamaluddin Moloo, MD, MPH

Published in Journal Watch General Medicine June 8, 2010