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Nutrition and You: Proton Pump Inhibitors
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Are They Inhibiting More than Acid? 


Proton pump inhibitors (PPIs) work by blocking the production of acid from the cells in your stomach. Your clinician may recommend the addition of a PPI to your home parenteral or enteral nutrition (HPEN) regimen if needed to reduce the amount of acid produced. Histamine H2-receptor blockers are another type of acid-reducing medications, but these work on different cells to reduce the effect of excess acid production. PPIs appear to be more effective and safer than H2 blockers and have become the preferred medication for reducing the amount of acid in the stomach. In some cases, a prescriber may use both PPIs and histamine H2-receptor blockers in a nutrition support patient.

 

Since some PPIs are now available over-the-counter, long-term (or even lifetime) use is common. Often this occurs without medical supervision or an appropriate indication (“as seen on TV” is not an appropriate indication!). Although these drugs are safe, new data has shown that long-term acid suppression from PPIs may reduce the absorption of important vitamins and nutrients. Recently, the U.S. Food and Drug Administration (FDA) revised the product labeling for PPIs to describe the possible increased risk of fractures with high-dose and long-term use. Since nutrition support consumers may already be at risk for nutritional deficiencies, fractures, and infections, the risk-to-benefit balance of using PPIs must be carefully evaluated on an individual basis. 

 

PPIs and Nutrition Support 

Acid is required for normal digestion. In patients receiving HPEN or those that secrete excessive amounts of gastric acid, PPIs are used to reduce the acidity and volume of gastric fluid produced. Knowing there are some potential risks associated with long-term use of PPIs and being familiar with early signs of complications, nutrition support teams and patients can work together to eliminate or reduce the risk of adverse outcomes.

 

Fractures and Calcium 

Many studies have concluded that PPIs are capable of affecting calcium absorption. Although short-term therapy was tolerated, long-term PPI therapy was associated with increased bone fractures, especially the hip. A history of smoking further increased the risk of PPI-associated fractures. The risks and benefits for continuing long-term PPI therapy should be assessed. If oral calcium supplementation is recommended, the soluble citrate salt form is preferred rather than the carbonate formsince it is ready to absorb without acid. 

 

Vitamin B12

B12 is in the multivitamin infusion that most HPN patients receive and in most oral multivitamins. Deficiencies in vitamin B12 have been noted in patients receiving PPIs even if supplemented with the recommended dietary allowance of 7 to 50 mcg/day. Vitamin B12 is bound to other nutrients; it needs the acidity of gastric juice in order to be released and absorbed. Since PPIs decrease gastric acidity, B12 deficiency can occur.

 

Symptoms of deficiency may include loss of concentration, fatigue, and lightheadedness. Chronic vitamin B12 deficiency can lead to neurologic disorders, depression, and dementia, which can be reversible if diagnosed in a timely manner. In addition, vitamin B12 is crucial for bone formation. Even without symptoms, vitamin B12 serum levels should be checked after three to four years of chronic PPI use.

 

Magnesium

PPIs may affect the absorption of magnesium from the GI tract if used long-term. Providers should monitor for unexplained manifestations of magnesium and potassium deficiencies in long-term PPI users. Of note, when magnesium levels remain low, potassium levels will also drop. Fortunately, the low magnesium levels appear to be reversible upon stopping PPIs. 

 

Infections

An increased risk of GI infection has been associated with decreased gastric acid levels. When gastric acid is blocked or significantly reduced, as occurs with PPI use, the body is not able to kill certain bacteria or parasites, therefore increasing the potential for GI infections from sensitive organisms such as salmonella, C. difficile, and giardia. It is important for patients to immediately notify their health care provider if they experience unexplained and persistent vomiting and/or diarrhea, bloody stools, fevers, or pain.

 

Factors to Consider

With the widespread use of PPIs, the safety of long-term use needs to be considered and monitoring is key to ensuring the best possible outcome for every patient. For the nutrition support team to determine if long-term PPI use is beneficial, they should regularly evaluate the patient to assure:
  1. The indication for the PPI is appropriate and still relevant;
  2. Long-term acid suppression continues to be necessary (perhaps the patient has decreased HPN or is eating regular meals as well);
  3. Signs and symptoms of vitamin B12, calcium, and magnesium deficiencies are monitored.
Additionally, patients should report any new signs or symptoms of the deficiencies discussed above, as well as any new medication (over-the-counter or prescribed) or supplement to their nutrition support specialist and primary care physician. 

 

Conclusion

As with any medication, there are benefits and risks. With careful monitoring by the nutirtion support team, PPI use can be a successful component of HPEN management.

 

Written by Negin Moon, Mercer University College of Pharmacy, Doctor of Pharmacy Candidate, 2014; Kevn M. McNamara, PharmD, CNSC; and Brenda L. Gray, PharmD, CNSC, BCNS, BioScrip Infusion.Reviewed by Carol Ireton-Jones, PhD, RDN, CNSC, and Laura Matarese, PhD, RD, CNSC. References available upon request.


Examples of PPIs:

  • omeprazole (Prilosec®)
  • lansoprazole (Prevacid®)
  • dexlansoprazole (Dexilant®)
  • pantoprazole (Protonix®)
  • esomeprazole (Nexium®)
  • rabeprazole (Aciphex®)

Examples of histamine
H2-receptor blockers:

  • ranitidine (Zantac®)
  • famotidine (Pepcid®)
  • cimetidine (Tagamet®) 

LifelineLetter, May/June 2014

 

more Calendar

9/26/2016 » 9/30/2016
Malnutrition Awareness Week

5/6/2017
Oley Regional Conference

This website is an educational resource. It is not intended to provide medical advice or recommend a course of treatment. You should discuss all issues, ideas, suggestions, etc. with your clinician prior to use. Clinicians in a relevant field have reviewed the medical information; however, the Oley Foundation does not guarantee the accuracy of the information presented, and is not liable if information is incorrect or incomplete. If you have questions please contact Oley staff.

 

Updated in 2015 with a generous grant from Shire, Inc. 

 

This website was updated in 2015 with a generous grant from Shire, Inc. This website is an educational resource. It is not intended to provide medical advice or recommend a course of treatment. You should discuss all issues, ideas, suggestions, etc. with your clinician prior to use. Clinicians in a relevant field have reviewed the medical information; however, the Oley Foundation does not guarantee the accuracy of the information presented, and is not liable if information is incorrect or incomplete. If you have questions please contact Oley staff.
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