Acid-Suppressive Therapy May Increase Risk of Community-Acquired Pneumonia CME

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Acid-Suppressive Therapy May Increase Risk of Community-Acquired

Pneumonia  CME

News Author: Laurie Barclay, MD

CME Author: Vega, MD, FAAFP

Disclosures

To earn CME credit, read the news brief along with the CME information

that follows and answer the post test questions.

Release Date: October 26, 2004; Valid for credit through October 26,

2005

Credits Available

Physicians - up to 0.25 AMA PRA category 1 credit(s)

Oct. 26, 2004 — Gastric acid-suppressive therapy increases the risk of

community-acquired pneumonia, according to the results of a case-control

analysis study published in the Oct. 27 issue of JAMA.

" Reduction of gastric acid secretion by acid-suppressive therapy allows

pathogen colonization from the upper gastrointestinal tract, " write

J.F. Laheij, PhD, from University Medical Center St. Radboud in

Nijmegen, the Netherlands, and colleagues. " The bacteria and viruses in

the contaminated stomach have been identified as species from the oral

cavity. "

Using the Integrated Primary Care Information database between Jan. 1,

1995, and Dec. 31, 2002, the investigators identified acid-suppressive

drug users with at least one year of valid database history, and they

compared incidence rates for pneumonia for unexposed and exposed

individuals.

A case-control analysis was conducted nested in a cohort of incident

users of acid-suppressive drugs to reduce confounding by indication.

Cases were all individuals with incident pneumonia during or after

stopping use of acid-suppressive drugs. For each case, up to 10 controls

were matched for practice, year of birth, sex, and index date. Using

conditional logistic regression, the investigators compared the risk of

community-acquired pneumonia in users of proton pump inhibitors (PPIs)

and of H2-receptor antagonists (H2RAs).

The primary outcome was community-acquired pneumonia, defined as certain

(proven by radiography or sputum culture) or probable (clinical symptoms

consistent with pneumonia).

Of 364,683 individuals, 5,551 developed first occurrences of pneumonia

during follow-up. Pneumonia incidence rates were 0.6 per 100

person-years in non-acid-suppressive drug users and 2.45 per 100

person-years in acid-suppressive drug users.

Compared with persons who stopped using PPIs, the adjusted relative risk

(RR) for pneumonia among persons currently using PPIs was 1.89 (95%

confidence interval [CI], 1.36 to 2.62), with a significant positive

dose-response relationship. Risk of pneumonia was increased 1.63-fold

(95% CI, 1.07 to 2.48) for current users of H2RAs compared with those

who stopped use, but the variation in dose was restricted.

Study limitations include possible misclassification of outcome,

diagnostic bias, misclassification of exposure, or confounding by

indication.

" Our results suggest that acid-suppressive drugs such as H2RAs and PPIs

are associated with an increased risk of community-acquired pneumonia,

probably because of reduction of gastric acid secretion, facilitating

oral infections, " the authors write. " To avoid the calculated excess

pneumonia, patients with asthma or chronic obstructive lung disease,

immunocompromised persons, children, and elderly persons should be

treated with acid-suppressive drugs only when necessary and with the

lowest possible dose. "

In an accompanying editorial, C. Gregor, MD, from the University

of Western Ontario in London, Canada, notes that acid-suppressive drugs

are safe, effective, and among the most widely prescribed medications

worldwide, with almost $13 billion in sales in 1998 and an annual growth

rate of 3%. "

However, as the indications for these drugs increase and as the

population ages, the number of patient-years of exposure will continue

to increase, and any previously unrecognized complications will come to

light.

" If acid suppression causes some cases of pneumonia, it is reassuring

that the risk is relatively small and that the complication in most

cases is usually amenable to therapy, " Dr. Gregor writes. " However, no

medication is without potential adverse effects. Concerns for patient

safety should guide initial prescribing and perhaps more importantly,

chronic use of even the most apparently benign drug. "

JAMA. 2004;292:1955-1960, 2012-2013

Carol in IL

Mom to  seven kid,  twin grandson's and , 4 DS

" Unless the Lord builds the house, they labor in vain. " Psalm 127

 

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