The Beauty and Sorrow of Using Proton Pump Inhibitors in Patients With Cirrhosis

Abstract

I read with interest the article regarding the use of proton pump inhibitors (PPIs) in patients with cirrhosis.1Mahmud N. et al.Gastroenterology. 2022; 163: 257-269.e6Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar Mahmud et al showed that the use of PPIs was associated with a 12% decrease in the risk of mortality related to nonhepatic causes and a 23% increased risk of liver-related mortality. Although interesting, several points warrant further clarification. The mixing effects of PPIs on patients with cirrhosis would be a difficult situation for both clinicians and patients. In this retrospective analysis, the indications for using PPIs were not known. The use of PPIs demonstrated a protective association in patients with hospitalization for gastrointestinal bleeding. This may imply that PPIs could only possibly be administered in patients with cirrhosis with upper gastrointestinal bleeding. The incidence of gastroesophageal reflux disease is generally increased as compared with healthy individuals.2Li B. et al.BMC Gastroenterol. 2010; 10: 54-59Crossref PubMed Scopus (21) Google Scholar Our previous study showed that up to 24% of patients with cirrhosis had duodenal ulcers.3Lo G.H. et al.Gastrointest Endosc. 2005; 62: 350-356Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar The use of PPIs is regarded as the standard therapy for gastroesophageal reflux disease or peptic ulcer diseases.4Laine L. et al.Am J Gastroenterol. 2016; : 1-3Google Scholar If PPIs are detrimental for patients with cirrhosis without gastrointestinal bleeding, we need to know whether histamine H2 receptor antagonist (H2RA) could replace the role of PPIs in the hastening of ulcer healing, achieving rapid symptom relief and improving quality of life in patients with cirrhosis. If short-term PPIs are still allowed for patients with cirrhosis, it would be better to know what dose or duration causes no harm for patients with cirrhosis. In consideration of the potential harms of PPIs, it seems indicated that endoscopy be performed before using PPIs in patients with cirrhosis. Although short-term PPIs were without severe drawbacks,2Li B. et al.BMC Gastroenterol. 2010; 10: 54-59Crossref PubMed Scopus (21) Google Scholar,5Lo G.H. et al.J Gastroenterol Hepatol. 2013; 28: 684-689Crossref PubMed Scopus (29) Google Scholar the long-term use of PPIs in patients with cirrhosis awaits further prospective studies. The Association Between Proton Pump Inhibitor Exposure and Key Liver-Related Outcomes in Patients With Cirrhosis: A Veterans Affairs Cohort StudyGastroenterologyVol. 163Issue 1PreviewProton pump inhibitor use in cirrhosis is associated with increased risk of liver-related adverse outcomes, but may reduce mortality in patients hospitalized with gastrointestinal bleeding. Full-Text PDF ReplyGastroenterologyVol. 163Issue 6PreviewWe appreciate the interest in our article, “The Association Between Proton Pump Inhibitor Exposure and Key Liver-Related Outcomes in Patients With Cirrhosis: A Veterans Affairs Cohort Study,”1 and thank Wang et al, Lo, and Singh for their thoughtful Letters to the Editor. The authors raise several important limitations which, though generally acknowledged in the manuscript, would benefit from further discussion. First, they highlight that confounding by indication may be present in the study, given that we were unable to directly ascertain the reason for proton pump inhibitor (PPI) prescription. Full-Text PDF