According to the High Authority for Health (HAS), 16 million French people are treated by a proton pump inhibitor (PPI), drugs mainly prescribed for heartburn. Gold, “More than half of the uses would not be justified”, estimates the HAS in a report of November 2020. These drugs are, in fact, victims of their success. They are very effective but they can, in the event of prolonged use, generate side effects. Ultimately, HAS recommends that PPIs be “Less and better prescribed”.
Proton pump inhibitors: what are their indications?
PPIs are indicated in three situations:
- the gastroesophageal reflux disease (GERD),
- the’esophagitis(inflammation of the esophagus)
- or thestomach ulcer (in combination with an effective antibiotic treatment against the bacteria Helicobacter pylori).
Treatment should not exceed four weeks in GERD (on medical prescription), and four to eight weeks in case of stomach or duodenal ulcer. Beyond that, the situation must be reassessed by the doctor. “If the symptoms persist in the long term, it is imperative to see your attending physician to reorient the treatment according to additional examinations”, insists Prof. Dominique Deplanque, president of the National College of Medical Pharmacology. In most cases, a fibroscopy (examination of the stomach) is necessary to refine the diagnosis.
What is their mechanism of action?
In order to be able to dissolve and digest food, thestomach naturally secreteshydrochloric acid. In certain pathological situations (gastroesophageal reflux, stomach ulcer, etc.), this acid can cause unpleasant burns. PPIs will act on this symptom by blocking the action of proton pumps located on the surface of digestive cells.
“By their action, these drugs limit the acid secretion of the stomach”, summarizes Professor Deplanque.
This is why they are part of the therapeutic class of gastric antisecretories.
How to take his treatment?
PPIs act over 24 hours, which justifies once a day. The tablet is taken by swallowing a glass of water, preferably non-carbonated. Sparkling waters indeed facilitate reflux.
What are the available PPIs?
Proton pump inhibitors have been marketed in France since 1989. Most are available on prescription. Since 2009, several molecules have been freely available in pharmacies.
Prescription proton pump inhibitors
- Esomeprazole (Inexium + generics)
- Lansoprazole (Lanzor, Ogast + generics)
- Omeprazole (Mopral, Zoltum + generics)
- Pantoprazole (Eupantol, Inipomp + generics)
- Rabeprazole (Pariet + generics)
Proton pump inhibitors without a prescription
- Lansoprazole (Ogastoro)
- Omeprazole (Antrapro, Mopralpro, Prilosec)
- Pantoprazole (Pantozol control, Pantoloc control, Pantogastric, Ipraalox)
To consult: our medication sheets against gastroesophageal reflux
PPI in self-medication: are there any risks?
As a pharmacologist, Prof. Deplanque advises against the use of PPIs without a medical prescription. “I remain reluctant to self-medicate, he explains. The main pitfall is to make a mistake and miss the diagnosis which can be a severe ulcer or a cancerous lesion of the stomach which requires other treatments. “
High-risk associations with other drugs
- PPIs associated with anti-inflammatory drugs
Too often, PPIs are prescribed in combination with nonsteroidal anti-inflammatory drugs (NSAIDs), drugs known to be aggressive to the stomach. In its latest report, the Haute Autorité de santé estimates that this association is useless in 80% of cases.
For the HAS, only three situations justify listing PPIs and NSAIDs on the same prescription:
– in people over 65 years old,
– in patients with a history of gastric or duodenal ulcer,
– in patients taking an antiplatelet drug (with usual precautions).
- PPIs associated with antiplatelet agents
By their action, proton pump inhibitors can reduce the effectiveness of antiplatelet therapy (clopidogrel, etc.), intended to thin the blood after a heart attack. In these patients, Prof. Deplanque strongly advise against taking PPI for self-medication: “You must warn your doctor who, in the event of a prescription of PPI, will favor one of those which does not modify the metabolism of clopidogrel”.
What are the side effects of PPIs?
There are many questions about the adverse effects of PPIs. The table is not the same depending on the duration of use.
For short-term use
“In a context of normal use and over a short period of time, PPIs do not generate serious adverse effects. These are mild and infrequent, such as abdominal pain, diarrhea or constipation, nausea or vomiting, ”explains Prof. Deplanque.
For prolonged use
On the other hand, in its reassessment of November 2020, the Haute Autorité de santé recalls that “In the long term, a doubt remains about their profile of adverse effects and in particular in the event of prolonged misuse”. This risk is potentiated in elderly, frail and taking other medications.
It should be known, in fact, that by blocking the secretion of gastric acid, PPIs can in the long term (beyond 4 to 8 weeks of use) cause imbalances. Thus, some vitamins and minerals are less well absorbedby the body. Bacteria, which are no longer destroyed by the acidity of the stomach, can proliferate. In the end, the risk of certain pathologies is increased, especially :
- intestinal infections caused by bacteria such as Clostridium difficile;
- bone fractures, related to a disturbance in calcium absorption;
- the vitamin B12 deficiency with a risk of anemia.
- from magnesium deficiencies (rarer than vitamin B12 deficiency), with a risk of heart rhythm disturbances and seizures.
- hyponatremia, a decrease in sodium level in the blood, with the risk of confusion and lethargy.
- kidney damage, through immune and allergic reactions.
What do we know about the risk of digestive cancer?
Studies have sown doubt, suggesting an increased risk of digestive cancers, especially of the stomach, in connection withlong-term use of PPIs. In its report, the Haute Autorité de santé notes that the results are “Contradictory”. In the current state of knowledge, Professor Deplanque believes that “The risk is not established”.
Are they allowed during pregnancy and in children?
PPIs are not not contraindicated during pregnancy. However, medication should be avoided as much as possible in a pregnant woman. Professor Deplanque recalls this precautionary principle: “In a pregnant woman who is very embarrassed by gastroesophageal reflux disease, this type of treatment may be a solution. But be careful not to switch to chronic treatment. ”
In children, PPIs may be prescribed. But there is no formulation for toddlers under 1 year old. Recent studies have shown that children treated for a long time (over 3 months) with PPI have an increased risk of asthma, especially those under two years of age.
It is better to gradually stop a PPI-based treatment, and avoid stopping it overnight. “The interruption of treatment is sometimes associated with a rebound of gastric acidity, in particular in subjects who take PPIs chronically, beyond the prescription period”, observes Professor Deplanque.
What to replace PPIs with?
Other drugs can fight stomach pain, like the anti-acids (sodium bicarbonate or alginate, calcium carbonate …). Their mode of action is different from that of PPIs. “They act more like local dressings by neutralizing the acidity of the stomach”. They are effective, but on an ad hoc basis, unlike PPIs which act over 24 hours.