APR 26, 2016 7:48 AM PDT

Heartburn drugs in hospital raise death risk

Right now, in any US hospital, about half of the patients have a prescription for an acid-reducing drug to reduce heartburn or prevent bleeding in their stomach and gut.
 
As a result of the new findings, very few hospital patients should start taking or continue on PPIs as a preventive measure against gastrointestinal bleeding, according to Matthew Pappas.

But that well-intentioned choice may actually boost their risk of dying during their hospital stay, a new study finds. The drug may open them up to infections that pose more risk than bleeding would.

In fact, according to a computer simulation based on real-world risk and benefit data, around 90 percent of hospital inpatients who were first prescribed these drugs in the hospital have a higher risk of dying when they’re taking them, compared with their risk if they hadn’t gotten the prescription.

And for around 80 percent of patients who were already on these common drugs, called proton-pump inhibitors or PPIs, when they arrived at the hospital, staying on them also may lead to a small increase in the risk of dying.

The extra risk of death comes from the fact that reducing acid in the stomach can increase the risk of infections—especially pneumonia and Clostridium difficile, both of which pose a serious risk to hospitalized patients who develop them.

The study, which uses a computer model to achieve a result that otherwise would require an impractically large clinical trial, appears in the Journal of General Internal Medicine.

“Many patients who come into the hospital are on these medications, and we sometimes start them in the hospital to try to prevent gastrointestinal, or GI, bleeds,” says lead author Matthew Pappas, a hospitalist physician at the University of Michigan.

“But other researchers have shown that these drugs seem to increase the risk of pneumonia and C. diff, two serious and potentially life-threatening infections that hospitalized patients are also at risk for,” he continues.

“Our new model allows us to compare that increased risk with the risk of upper GI bleeding. In general, it shows us that we’re exposing many inpatients to higher risk of death than they would otherwise have—and though it’s not a big effect, it is a consistent effect.”

As a result of the new findings, he says, very few hospital patients should start taking or continue on PPIs as a preventive measure against gastrointestinal bleeding.
 

Rules of thumb


Pappas notes that nationally, some efforts have already shown ways to reduce the rate of new PPI prescriptions to hospitalized patients—about 20 percent of whom receive such orders right now.

But truly reducing PPI use in hospitals to the most appropriate patients—those with existing GI bleeding—will take more effort, Pappas predicts.

That’s because PPIs are built into many heuristics, or rules of thumb, that guide much hospital care. For instance, when a patient receives high-dose steroids in the hospital, the physician may automatically also prescribe a PPI to prevent the GI bleeding that steroids can cause.

“In fact, in running our simulation, we thought we would find some populations such as those on steroids or other medications often prescribed together with PPIs, who would not experience the increased mortality risk,” Pappas says. “But that turned out not to be the case.” GI bleeds are risky, it’s true. But hospital-acquired pneumonia and C. diff are much more common.

Although research is still needed on why PPI use increases a patient’s vulnerability to hospital-acquired pneumonia and C. diff infection, the effect of the acid-reducing drugs on gut bacteria likely has a direct impact. In the case of pneumonia, suppressing acid production may increase the amount of bacteria in the stomach and throat, which can then get into the lungs and cause pneumonia.
 

Comparing risk and benefit


Pappas notes that the model he developed with coauthor Sandeep Vijan and recent University of Michigan Ford School of Public Policy graduate Sanjay Jolly could be applied to many other situations where a common preventive or treatment measure in medicine also carries with it an increased risk of an unwanted effect.

Using such models, based on data from observational studies, could answer important questions in medicine without needing to carry out massive prospective clinical trials. To answer the question of whether the predicted increase in mortality risk caused by PPIs in inpatients is real, he says, would take a clinical trial of more than 64,000 patients randomly assigned to receive PPIs or not. Since PPIs are available as generic medications, the likelihood of such a study being funded and performed is nearly zero.

“Any time there are complex risk/benefit tradeoffs, without the possibility of a high-quality trial, this kind of simulation can help us come up with answers to inform clinical care,” says Pappas, also a VA Health Services Fellow.

For instance, he’s now studying the issue of “bridging” medication in patients who have been prescribed blood-thinning medications to prevent a stroke. Such patients often receive a prescription for an injected drug that will reduce stroke risk during the week or two before their regular oral drugs take effect. But that injection carries its own risk.

“Humans aren’t very good at recognizing very rare events, and reacting appropriately to things that are unlikely to happen,” says Pappas. “Physicians have an instinct to want to prevent very bad, though rare events—but everything we do carries risks. We need to be mindful of the things we are doing to prevent rare outcomes, and keep the risks in perspective. Computers can help.”

Vijan treats patients at the VA Ann Arbor Healthcare System and is a member of the VA Center for Clinical Management Research and University of Michigan’s Institute for Healthcare Policy and Innovation. Pappas is a clinical lecturer, and Vijan a professor, in the Medical School’s Division of General Medicine. The project’s only funding was Pappas’s fellowship support.

Source: University of Michigan

This article was originally posted on futurity.org.
About the Author
  • Futurity features the latest discoveries by scientists at top research universities in the US, UK, Canada, Europe, Asia, and Australia. The nonprofit site, which launched in 2009, is supported solely by its university partners (listed below) in an effort to share research news directly with the public.
You May Also Like
JUL 19, 2019
Cardiology
JUL 19, 2019
Heart Conditions Amongst The Most Misdiagnosed
There are a massive number of diseases that a person can acquire. This can make the idea of diagnosing a disease accurately seem like a daunting task. Shoc...
JUL 23, 2019
Cardiology
JUL 23, 2019
Shocking Numbers Of People Self-Prescribing Daily Aspirin
Up until recently, people who were concerned about the possibility of suffering a cardiac event were often advised to take low-dose aspirin daily. Because ...
DEC 19, 2019
Health & Medicine
DEC 19, 2019
Obesity on the rise in the United States
Even with a decade full of diet trends and superfoods, obesity rates in the United States continue to climb. According to a study published this week by 20...
JAN 03, 2020
Cardiology
JAN 03, 2020
Healthy Sleep May Offset Genetic Heart Disease Risk
People with a high genetic risk of heart disease or stroke may be able to offset that risk with healthy sleep patterns, according to new research. The rese...
JAN 15, 2020
Cardiology
JAN 15, 2020
Women's Blood Vessels Age Faster than Men's, Study shows
Around 75 million Americans have high blood pressure, or roughly 1 in every 3 adults. Now, new research has shown that women’s blood vessels age fast...
FEB 05, 2020
Cardiology
FEB 05, 2020
Protein-Rich Foods May Damage Heart Health
High-protein diets are becoming more and more popular as a method to both increase muscle mass and lose weight. Now however, new research is showing that e...
Loading Comments...