From the Guidelines
Proton Pump Inhibitors (PPIs) should be used with caution in patients with cirrhosis.
Risks and Benefits of PPIs in Cirrhosis
- PPIs have not shown efficacy for the management of acute variceal hemorrhage (AVH) 1
- A short course of PPI therapy after endoscopic variceal ligation (EVL) may reduce the size of post-banding ulcers 1
- Long-term use of PPIs can increase the risk of spontaneous bacterial peritonitis (SBP) and hepatic encephalopathy (HE) in cirrhotic patients 1
- PPIs can increase the incidence of HE by promoting microbial proliferation/dysbiosis in the small intestine and increasing intestinal membrane permeability 1
Recommendations for PPI Use in Cirrhosis
- PPIs should be used with caution and only when formally indicated 1
- The benefit-risk balance of PPI prescriptions should be systematically re-evaluated in patients with cirrhosis 1
- PPIs should be discontinued when possible, especially in patients with no formal indication for their use 1
From the Research
Association between Proton Pump Inhibitors (PPI) and Cirrhosis
- The use of PPIs in patients with cirrhosis has been associated with an increased risk of spontaneous bacterial peritonitis (SBP), decompensation events, and liver-related death 2.
- A study found that regular PPI use was associated with an increased cumulative probability of SBP compared to nonusers, and the risk of liver-related death was also significantly increased among regular PPI users 2.
- Another study suggested that high-dose PPI treatment is associated with a higher mortality in cirrhotic patients, and is an independent risk factor for recurrent hepatic encephalopathy, SBP, hepatorenal syndrome, and gastrointestinal bleeding 3.
Impact of PPI Therapy on Prognosis of Cirrhosis Patients
- A prospective observational cohort study found that PPI therapy does not affect prognosis of cirrhosis patients with acute decompensation and acute-on-chronic liver failure 4.
- However, a meta-analysis of 28 studies with 260,854 cirrhotic patients found that the use of PPIs is associated with an increased risk of long-term mortality, hepatic decompensation, hepatic encephalopathy, SBP, and overall infection in cirrhotic patients 5.
Clinical Trials and Studies
- The STOPPIT trial is a prospective, multicentre, randomized, double-blinded, placebo-controlled trial that evaluates the effects of discontinuation of pre-existing PPI treatment on the clinical course of cirrhosis in patients with complicated liver cirrhosis 6.
- The trial aims to determine whether discontinuation of PPI treatment delays a composite endpoint of re-hospitalization and/or death in patients with liver cirrhosis compared to patients on continued PPI medication 6.
Key Findings
- The use of PPIs in cirrhotic patients may be associated with an increased risk of adverse events, including SBP, decompensation, and liver-related death 2, 3, 5.
- However, the impact of PPI therapy on the prognosis of cirrhosis patients is still unclear, and further studies are needed to determine the optimal use of PPIs in this population 4.