They have been dragged into the dock with the most serious charges: contributing to bone fractures, intestinal and lung infections, tumors, kidney failure, cardiovascular problems and even Alzheimer’s disease. The latest studies, however, seem to clear them with full formula.
Regarding gastroprotectors, and in particular proton pump inhibitors, drugs widely used to treat various diseases of the digestive system and counteract stomach acid disorders, the debate has always been very heated, despite their proven effectiveness in blocking the production of hydrochloric acid in the stomach with a long-lasting coverage, and in avoiding damage – such as bleeding – to the gastric mucosa.
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To put an end to it comes a recent umbrella review, published in the magazine Alimentary Pharmacology & Therapeutics, that analyzing the data of 42 systematic reviews on large groups of patients did not identify a correlation between their intake and the risk of developing other types of diseases. The results are in line with those of another large study, which appeared in 2017 on Gastroenterology by the Universities of Tennessee and Pennsylvania, in which it was highlighted that most of the analyzes conducted are observational, and not enough evidence has so far emerged to question the safety of proton pump inhibitors, which are recommended for treatment gastroduodenal ulcers and gastroesophageal reflux.
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“The only two associations for which there is scientific evidence concern lower gastrointestinal infections, especially in hospitalized and co-morbid elderly, and the risk of infectious complications in patients with advanced liver disease”, he explains. Edoardo Vincenzo Savarino, associate professor of Gastroenterology at the University of Padua and advisor to the Italian Society of Gastroenterology and Digestive Endoscopy.
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“When we talk about these drugs, the primary problem is not the side effects, but the incorrect use made of them. This is especially true for the protection of the digestive tract in patients who take, for example, antiplatelet drugs, steroids, polytherapies but who, presenting specific risk factors, they would not need gastroprotectors “. Their abuse is quite frequent, because in many cases they are not taken correctly, or they are taken for too long periods, or even following do-it-yourself therapeutic schemes.
A study conducted by the University of Genoa and published on Digestive and Liver Disease found that in 40% of patients taking long-term proton pump inhibitors (more than 8 weeks) the prescription of these drugs is inappropriate. According to other analyzes, one in two patients takes proton pump inhibitors (such as pantoprazole, omeprazole and analogues) without actually needing them. With important costs for the health service, confirmed by the latest Aifa report on the use of drugs in Italy in 2020.
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In fact, drugs for the gastrointestinal system, together with those for metabolism, represent the third therapeutic category with the highest public expenditure for 2020, equal to 12.5% of total expenditure, with proton pump inhibitors – which record an increase annual use of 4.2% and over 6 million packages sold – driving costs. Unsurprisingly, pantoprazole occupies the highest positions among the top 30 active ingredients by contracted expense. To this must be added the other types of gastroprotectors, such as antacids and H2 receptor antagonists, which are largely available without prescription.
While it is true that there has been an increase in the prevalence of gastroesophageal reflux disease, from 7.9% in 2009 to 18.7% in 2018, “this does not justify such a large increase in prescriptions for these drugs,” he warns. the Aifa OsMed report. It is estimated that 20% of the general population, mostly women, use gastroprotectors. A share that rises up to 50% in the elderly over 75 years.
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“The consolidated indications for the use of proton pump inhibitors concern the treatment of gastroesophageal reflux disease, gastroduodenal ulcers, Helicobacter pylori infection, gastric lesions caused by taking non-steroidal anti-inflammatory drugs – explains the gastroenterologist – I main reasons for inappropriate use are the prevention of gastroduodenal ulcers in low-risk patients, monotherapy with cortisones, the use of antiplatelet agents such as aspirin without additional risk factors for gastroduodenal lesions, prolonged treatment of functional dyspepsia or a incorrect diagnosis of acidity-related disorders “.
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So taking cardioaspirin or other antiplatelet drugs, or anticoagulants, or non-steroidal anti-inflammatory or painkillers – to name the most common drugs – does not automatically imply the need to take the gastroprotector. “Each patient – Savarino specifies – must always be evaluated case by case, analyzing individual risk factors”. These include age, a history of peptic disease, previous bleeding, concomitant use of specific drug categories.
The Italian Association of Gastroenteorologists and Hospital Endoscopists has also intervened recently to reiterate that when gastroprotectors are used correctly, i.e. with appropriate indication, adequate dosage and recommended duration (which can be limited to a few weeks or even last long term), the advantages far outweigh the potential undesirable effects: “If this were not the case – the specialists comment – it would not have been possible to use them for over 30 years in millions of patients”.
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But if the international guidelines are clear, why is there still so much overuse of these drugs, both in hospitals and in local medicine? “Because there is a lack of a culture of” de-prescribing “- says Savarino – that is, the suspension of drugs that are no longer necessary, which must pass from adequate information to prescribers and from patient awareness to correct use”. For the latter, gastroprotectors are often a safe port to land, due to the effectiveness and speed with which they act in relieving burning and pain in the digestive tract, so much so that many continue the therapy over time for fear of a return of symptoms.
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Basically, there remains a golden rule that should not be underestimated: “When the symptoms are mild, the first measure to be adopted passes from changing the wrong lifestyles, starting with attention to nutrition, avoiding, for example, acidic foods that can irritating the mucosa in case of reflux – concludes the specialist – It is certainly less immediate than a pill that immediately gives relief, but it is a strategy that depends on us, and in the end it pays off “.
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