Category Archives: General Health

Piling on PPIs -Now Concerns about Dementia

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A recent study (see abstract below -from Mike Hart) indicates the possibility that proton pump inhibitors (PPIs) could increase the risk of dementia to a small degree.  Despite the big numbers, this study cannot adequately control for numerous factors that could influence these results.  As is often said, association does not prove causation.  Nevertheless, this study is another reminder to use PPIs when indicated and to use them for the appropriate length of therapy.

Here’s NBC News Narrative: Popular Heartburn Drugs Linked to Dementia

ONLINE FIRST

Association of Proton Pump Inhibitors With Risk of Dementia: A Pharmacoepidemiological Claims Data Analysis

Willy Gomm, PhD1; Klaus von Holt, MD, PhD1; Friederike Thomé, MSc1; Karl Broich, MD2; Wolfgang Maier, MD1,3; Anne Fink, MSc1,4; Gabriele Doblhammer, PhD1,4,5,6; Britta Haenisch, PhD1

JAMA Neurol. Published online February 15, 2016. doi:10.1001/jamaneurol.2015.4791
 
ABSTRACT

Importance  Medications that influence the risk of dementia in the elderly can be relevant for dementia prevention. Proton pump inhibitors (PPIs) are widely used for the treatment of gastrointestinal diseases but have also been shown to be potentially involved in cognitive decline.

Objective  To examine the association between the use of PPIs and the risk of incident dementia in the elderly.

Design, Setting, and Participants  We conducted a prospective cohort study using observational data from 2004 to 2011, derived from the largest German statutory health insurer, Allgemeine Ortskrankenkassen (AOK). Data on inpatient and outpatient diagnoses (coded by the German modification of the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision) and drug prescriptions (categorized according to the Anatomical Therapeutic Chemical Classification System) were available on a quarterly basis. Data analysis was performed from August to November 2015.

Exposures  Prescription of omeprazole, pantoprazole, lansoprazole, esomeprazole, or rabeprazole.

Main Outcomes and Measures  The main outcome was a diagnosis of incident dementia coded by the German modification of the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision. The association between PPI use and dementia was analyzed using time-dependent Cox regression. The model was adjusted for potential confounding factors, including age, sex, comorbidities, and polypharmacy.

Results  A total of 73 679 participants 75 years of age or older and free of dementia at baseline were analyzed. The patients receiving regular PPI medication (n = 2950; mean [SD] age, 83.8 [5.4] years; 77.9% female) had a significantly increased risk of incident dementia compared with the patients not receiving PPI medication (n = 70 729; mean [SD] age, 83.0 [5.6] years; 73.6% female) (hazard ratio, 1.44 [95% CI, 1.36-1.52]; P < .001).

Conclusions and Relevance  The avoidance of PPI medication may prevent the development of dementia. This finding is supported by recent pharmacoepidemiological analyses on primary data and is in line with mouse models in which the use of PPIs increased the levels of β-amyloid in the brains of mice. Randomized, prospective clinical trials are needed to examine this connection in more detail.

Related blog post: Proton Pump Inhibitors Webinar

Unrelated article (from Ben Gold): J Molina-Infante et al. Am J Gastroenterol 2015; 110: 1567-1575.  This study examined 75 patients (mean age 38 years) with proton-pump inhibitor responsive esophageal eosinophilia (PPI-REE).  55 (73%) had long-term sustained histologic remission with low-dose PPI therapy (20 mg once or twice daily). In addition, the article noted that 9 of 10 relapsers with distal eosinophilia were noted to have a CYP2C19 rapid metabolizer genotype and regained histologic remission with dose intensification.

Briefly noted: AI Sharara et al. Clin Gastroenterol Hepatol 2016; 14: 317-21.  Among 414 who met inclusion criteria (at least 6 months of PPI usage and at least 1 serum magnesium level), 57 (13.8%) had at least 1 low serum magnesium –44 of these patients had recognizable causes (eg. diuretics, chronic diarrhea).  Of the remainder who continued with PPI therapy, the level was normal at final measurement and only mildly low levels were noted previously.  Thus, in patients without other reasons for low magnesium, the authors found that use of a PPI does not appear to be associated with hypomagnesemia.

 

Trends in Non-medical Opiod Use and Heroin Addiction

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Almost all physicians use opiods in their practice and need to keep up with the challenges of pain management and addiction.  An update on the problem of non-medical opiod use and heroin addiction from NEJM:

Full article link: Relationship between Nonmedical Prescription-Opiod Use and Heroin Use

An excerpt:

The transition from nonmedical use of prescription opioids to heroin use appears to be part of the progression of addiction in a subgroup of nonmedical users of prescription opioids, primarily among persons with frequent nonmedical use and those with prescription opioid abuse or dependence. Although some authors suggest that there is an association between policy-driven reductions in the availability of prescription opioids and increases in the rates of heroin use,16,18 the timing of these shifts, many of which began before policies were robustly implemented, makes a causal link unlikely…

In the majority of studies, the increase in the rates of heroin use preceded changes in prescription-opioid policies, and there is no consistent evidence of an association between the implementation of policies related to prescription opioids and increases in the rates of heroin use or deaths, although the data are relatively sparse. Alternatively, heroin market forces, including increased accessibility, reduced price, and high purity of heroin appear to be major drivers of the recent increases in rates of heroin use…

Fundamentally, prescription opioids and heroin are each elements of a larger epidemic of opioid-related disorders and death. Viewing them from a unified perspective is essential to improving public health. The perniciousness of this epidemic requires a multipronged interventional approach that engages all sectors of society.

Related blog posts:

 

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Guts and Valentines?

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I learned this week that the Crohn’s & Colitis Foundation of America (CCFA) was founded in part  based on a love story:

From CCFA: Irwin M. Rosenthal, one of the visionary co–founders of CCFA, and Suzanne were due to be married in a few months time when suddenly Suzanne became very ill. Motivated by her struggle with Crohn’s disease, Irwin, along with William and Shelby Modell, and Dr. Henry D. Janowitz, established the Foundation for Research in Ileitis, now known as the Crohn’s & Colitis Foundation of America.

To send an CCFA eValentine: CCFA Valentine E-card

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“A Healthy Diet’s Main Ingredient? Best Guesses”

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A recent commentary from the NY Times (A Healthy Diet’s Main Ingredients? Best Guesses) explores some of the failed efforts to improve health by reducing fat or eliminating eggs and explains why these are no longer recommended.  The article has a 12 minute video which reviews some of the confusion regarding dietary recommendations.

Here’s an excerpt:

Conventional wisdom held that fat was bad, period, with relatively few Americans distinguishing between saturated fats (meat, eggs, dairy products) and healthier unsaturated fats (fish, vegetable oils, nuts). Typically, people turned to breads, cereals and potatoes — and to sugary soft drinks — for the calories they no longer got from protein-rich foods…The result? Carbo-loading Americans grew fatter. “We put the whole country on a low-fat diet,” Mr. Taubes said, “and, lo and behold, we have an obesity epidemic.”…

New guidelines are expected to be issued this month by the Departments of Agriculture and of Health and Human Services, which tend to follow the recommendations of an advisory committee. One likely eye-catcher is a new assessment of cholesterol, long an archvillain. It seems destined for rehabilitation to some degree. Months ago, the advisory committee concluded that the dietary intake of cholesterol (the body produces this waxy, artery-obstructing matter on its own) had no real effect on blood levels of LDL, the so-called bad cholesterol. “Cholesterol,” the committee said, “is not a nutrient of concern for overconsumption.”

There is a conspicuous American tendency to cling to a favored diet as the gateway to good health, keeping weight down, staving off cancers and banishing heart attacks. A consequence is an abundance of regimens — vegan, gluten-free, Paleolithic, fruitarian and many more — each promoted by its adherents as the one true path.

But nutrition experts, including those in this Retro Report, caution that life is complex, and that we are more than what we eat.

Related blog posts:

About Mentors

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I found a recent perspective (Y Tache. Gastroenterol 2015; 149: 1662-65) on mentoring of interest, particularly on the historic basis which I had forgotten.

“In Homer’s book, the Odysseus, Mentor was a loyal friend and adviser to Odusseus (Ulysses), King of Ithaca.  When Ulysses left his kingdom to participate in the Trojan War, he entrusted Mentor with the education of his son, Telemachus…This character of Greek mythology became famous only at the beginning of the 18th century in the context of the didactic French novel entitled “Les Aventures de Telemaque.”

My take: it is interesting to understand where the term “mentor” comes from.  I feel fortunate to have had some terrific mentors.

 

 

The Push to Improve Diagnosis

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The Institute of Medicine’s (now called the National Academy of Medicine) “Improving Diagnosis in Health Care” (the link includes a link to a 1-hour briefing) is receiving a lot of attention. One recent commentary (H Singh, ML Graber. NEJM 2015; 373: 2493-95) elaborates on this issue. The IOM reports notes that “diagnostic errors affect at least 1 in 20 U.S. adults in outpatient settings each year, or 12 million adults per year.”

The report recommends “strengthening teamwork, reforming the teaching of diagnosis, ensuring that health information technology (IT) supports the diagnostic process, measuring and learning from errors in real-world practice, promoting a culture of diagnostic safety, reforming the malpractice and reimbursement systems, and increasing research funding.”

My take: This report highlights an enormous challenge for the healthcare system.  While IT support in theory sounds like it could help, right now IT isn’t helping much.  Many physicians are bogged down inputting data and trying to find enough time for critical thinking.  There is a lot of work ahead.