Proton pump inhibitors should continue to be used

Patients with a proven indication for proton pump inhibitors (PPIs) should continue to receive them in the lowest effective dose, despite recent concerns about their long-term safety, the ISG Annual Winter Meeting was told by a US expert in the area.

Dr Colin Howden, Gastroenterologist Specialist, University of Tennessee, Memphis, US, discussed how safety issues associated with PPIs have recently attracted widespread media and lay attention and noted that gastroenterologists are now being frequently asked about the appropriateness of PPI therapy for specific patients.

Furthermore, some patients may have had PPI therapy discontinued abruptly or inappropriately due to these safety concerns.

Reviewing the evidence on the proposed adverse consequences of PPI therapy, Dr Howden maintained that it is inadequate to establish causal relationships between PPI therapy and many of the proposed associations.

Residual confounding related to study design and the over-extrapolation of quantitatively small estimates of effect size have probably led to much of the current controversy about PPI safety, he said. In turn, this has caused unnecessary concern among patients and prescribers. That said, PPI dose escalation and continued chronic therapy in those unresponsive to initial empiric therapy is discouraged, he added.

Speaking to the Medical Independent (MI), Dr Howden reiterated his key point that PPIs are generally safe when correctly indicated, and remain key to the management of a number of conditions affecting the upper gastrointestinal tract, including gastroesophageal reflux disease, Barrett’s oesophagus, eosinophilic oesophagitis, and dyspepsia.

“PPIs are very useful drugs and a number of patients take them for very good reasons and generally derive a lot of benefit from them. They have been linked to a whole host of possible adverse outcomes, but the level of evidence for many of these associations is very weak. I think if physicians or patients have concerns, they should make sure they are on the PPI for a valid reason, as many patients take these medications inappropriately. If the patient is on PPIs for a valid reason and is doing fine, then as long as the drug is being taken in the lowest effective dose, there is really no need to be concerned.”

Meanwhile, speaking during the inflammatory bowel disease (IBD) session, Dr Anthony O’Connor, Consultant Gastroenterologist, Tallaght University Hospital, Dublin, said quality-of-life issues in IBD patients are not being adequately considered by clinicians and researchers.

He pointed out that IBD severely impacts quality-of-life across a number of domains, including fatigue, depression, pain and changes in body image and argued that trying to ensure the best quality-of-life for patients should be key in the treatment approach. However, he contended that clinicians, while focusing on disease scores and measurable outcomes often do not ask simple yet vital questions, like how is the patient’s social and sex life. He said treat-to-target and mucosal healing must not be at the exclusion of quality-of-life.

“A multidisciplinary, multimodality approach is required to address the quality-of-life issues our patients face.”

Dr O’Connor is now working on furthering Irish research into this area.

At the end of the meeting, there was an update on the work of INITIative, the first collaborative research network for IBD in Ireland. The network is open to clinical and scientific investigators with an interest in Crohn’s disease and ulcerative colitis throughout the island of Ireland.

Speaking to MI, Network Chair Prof Glen Doherty said INITIative has been recruiting for a number of trials and studies over the last year and is on track to meet its recruitment targets.

These include the I-CARE study, which is the first observational European prospective cohort study that will provide unique information (safety, efficacy, risk-benefit ratio and healthcare costs) on the long-term use of recommended therapy in IBD, using a predefined, standardised follow-up. This real-world data will be used to guide clinicians as well as healthcare authorities to provide the best care for IBD patients by optimising available therapies.

“Recruitment began in Ireland in May 2017 and we have recruited almost 400 patients from Ireland and we have our own clinical trial, GOAL-ARC [a nationwide, multi-centre, investigator-initiated, randomised, controlled trial to evaluate the use of personalised golimumab (GLM) dose adjustment in ulcerative colitis], which has been recruiting successfully, and we are at nearly 50 per cent recruitment for that study. So our focus now, going forward, is trying to involve other disciplines who are interested in IBD to collaborate and thus improve the impact of IBD research being done in Ireland.”