AASLD: Proton Pump Inhibitors May Be Problematic for Cirrhosis Patients

BOSTON, Nov. 5 -- Use of proton pump inhibitors (PPIs) in patients with cirrhosis was associated with a risk of spontaneous bacterial peritonitis and Clostridium difficile-associated disease, according to two retrospective studies.
Action Points
Explain to patients with cirrhosis that this study suggests that they be monitored carefully while on proton pump inhibitors for spontaneous bacterial peritonitis and Clostridium difficile-associated disease.
Note that these studies were published as an abstract and presented at a conference. The data and conclusions should be considered to be preliminary until published in a peer-reviewed publication.
PPI therapy was independently associated with peritonitis, despite a higher antibiotic prophylaxis rate among patients who developed the condition compared with patients who did not, Jasmohan S. Bajaj, M.D., M.S., of the Medical College of Wisconsin at Milwaukee, told attendees at the American Association for the Study of Liver Diseases meeting here.
Dr. Bajaj and colleagues also used the same 985 hospitalized patients with cirrhosis in a case-control study to learn if PPI therapy increases the rate of Clostridium difficile in that population.
Patients with cirrhosis are often prescribed a PPI because of their propensity to develop upper GI symptoms and bleeding, Dr. Bajaj said. But the medications promote bacterial overgrowth and have been associated with infection.
In the first study, univariate logistic regression showed that Child's (CTP) score (P=0.0001, OR: 9.9, CI: 3.4 to 28.8) and PPI use (P=0.0001, OR: 7.8, CI: 3.4 to 18) were significantly higher among the peritonitis patients than in those who did not have peritonitis. The two patient groups were matched by age alone and by age and CTP score.
On multivariate analysis, CTP score (P=0.0001, OR: 9.3, CI: 4 to 30) and PPI use (P=0.0001, OR 6.4, CI: 2.5 to 16) were also significant.
More than a third of the peritonitis patients (36%) had received antibiotic prophylaxis compared with less than a quarter (22%) of the controls.
More than two-thirds of peritonitis patients (68%) were on a PPI compared with about a third (32%) of the patients who did not have peritonitis.
The researchers also found that inappropriate use of PPIs was higher in the peritonitis patients (53%) than in patients who did not have peritonitis (32%). Use was defined as appropriate when PPIs were taken for GERD, Barrett's esophagus, nonvariceal GI bleed, and peptic ulcer; other uses were defined as inappropriate.
In the C. difficile study, both PPI use and antibiotic use (primarily for pneumonia and suspected septicemia) were associated with a higher risk of Clostridium difficile-associated disease, said Dr. Bajaj.
The study's variables included age, CTP score, race, reason for admission that was liver-related, antibiotic use, prophylaxis against sudden bacterial peritonitis, and PPI use.
On univariate logistic regression with Clostridium difficile-associated disease as the outcome, only antibiotic use (P0.0001, OR: 6.7, CI: 3.2 to 14) and PPI use (P0.0001, OR: 8, CI: 3.4 to 19) were significant predictors.
On multivariate analysis, PPI use (P0.0001, OR: 6.1, CI: 3 to 14) and antibiotic use (P0.0001, OR 7.8, CI: 3.2 to 19) were again significantly associated with C. difficile disease.
The researchers noted neither funding source for the study nor financial conflicts.Primary source: American Association for the Study of Liver DiseasesSource reference: Bajaj JS, et al "Proton Pump Inhibitor Use is Associated with a High Risk of Spontaneous Bacterial Peritonitis" Abstract 740 presented Nov. 4. Additional source: American Association for the Study of Liver DiseasesSource reference: Bajaj JS, et al "Clostridium Difficile Infection Is Associated with Proton Pump Inhibitors in Patients with Cirrhosis" Abstract 773 presented Nov. 4.