From the Guidelines
Pantoprazole is the preferred proton pump inhibitor (PPI) in patients with cirrhosis and continued alcohol intake, due to its lower risk of drug interactions and impact on the cytochrome P450 enzyme system. When prescribed, the recommended dosage is typically 40 mg once daily, though this may be reduced to 20 mg daily in severe hepatic impairment 1.
Key Considerations
- PPIs should be prescribed at the lowest effective dose for the shortest duration necessary, as they can increase the risk of spontaneous bacterial peritonitis, Clostridium difficile infection, and hepatic encephalopathy in cirrhotic patients, especially those with ongoing alcohol use 1.
- Regular reassessment of the need for PPI therapy is essential, with consideration of step-down therapy to H2 receptor antagonists or discontinuation when possible.
- Patients should be counseled that alcohol cessation remains the most important intervention for their liver health, regardless of acid-suppression therapy.
Rationale
- The use of PPIs in cirrhotic patients with continued alcohol intake requires careful consideration of the potential risks and benefits, as highlighted in a recent cohort study that found an increased risk for covert HE and development of overt HE in cirrhotic patients with long-term use of PPIs 1.
- The French recommendations for the diagnosis and management of hepatic encephalopathy also emphasize the importance of systematically re-evaluating the benefit–risk balance and appropriateness of PPI prescriptions in patients with cirrhosis 1.
From the Research
Preferred PPI in Cirrhosis and Continued Alcohol Intake
- The use of proton pump inhibitors (PPIs) in patients with cirrhosis is a common practice, but it requires careful consideration due to the potential risks of infections and hepatic encephalopathy 2.
- A study published in 2018 classified esomeprazole, omeprazole, and rabeprazole as having "no additional risks known" in patients with cirrhosis, while pantoprazole and lansoprazole were classified as "unsafe" due to increased exposure 2.
- Another study published in 2021 found that omeprazole, esomeprazole, and lansoprazole inhibited microsomal activity in patients with cirrhosis, while pantoprazole and rabeprazole did not have a significant impact 3.
- A retrospective study published in 2024 found that there is a concerning overprescription of PPIs in cirrhotic patients, often deviating from established guidelines, which subjects patients to unnecessary risks 4.
- In terms of managing gastrointestinal bleeding in patients with cirrhosis, a study published in 2016 highlighted the importance of optimal management to achieve haemostasis and address complications such as liver failure, infection, or renal failure 5.
- A prospective randomized clinical trial protocol published in 2021 compared the efficacy of oral omeprazole versus intravenous omeprazole in decreasing rebleeding of peptic ulcer patients, but excluded patients with liver cirrhosis 6.
PPIs and Alcohol Intake
- There is no direct evidence in the provided studies on the preferred PPI in cirrhosis and continued alcohol intake.
- However, it is essential to consider the potential risks and benefits of PPI use in patients with cirrhosis, particularly those with continued alcohol intake, and to carefully evaluate the appropriateness of PPI prescriptions in these patients 2, 4.