A222 ASSOCIATION BETWEEN PROTON PUMP INHIBITOR USE AND DEVELOPMENT OF HEPATIC ENCEPHALOPATHY AND SPONTANEOUS BACTERIAL PERITONITIS IN HOSPITALIZED PATIENTS WITH CIRRHOSIS

Abstract Background Proton pump inhibitors (PPIs) are commonly prescribed medications which are indicated in various different gastrointestinal (GI) diseases, including peptic ulcer disease, gastroesophageal reflux disorder and upper GI bleeding. There is some evidence to suggest that PPI use in cirrhosis may predispose to the development of hepatic encephalopathy (HE) and spontaneous bacterial peritonitis (SBP), albeit with some controversy. Aims We aim to conduct a retrospective epidemiological analysis of the association between PPI use in hospitalized patients with cirrhosis and prevalence of HE and SBP. Methods This was a retrospective cohort study of 953 adult patients (mean age 62.3 (SD=12.2)) with cirrhosis admitted to the Ottawa Hospital between January 1, 2011 and December 31, 2015. A chart review was conducted and relevant information extracted. Results Average MELD-Na on admission was 17.4 (SD = 7.5) with no significant differences when stratified by in-hospital PPI use (p=0.53). 14.7% of patients had a prior history of HE, 5.4% SBP, 31.6% ascites, 9.3% hepatocellular carcinoma and 1.2% hepatorenal syndrome. 26.4% of patients had a history of varices, of which 34.4% had previous variceal bleeding. 45.4% of patients were on a PPI prior to admission and 69.8% during their hospitalization. Patients with a previous history of HE (16.8% vs. 9.6% p=0.006), varices (31.4% vs. 14.2% p<0.001) and variceal bleed (11.6% vs. 3.1% p<0.001) were more likely to be exposed to a PPI in-hospital. Mortality rate during index admission was 19.4%. There was no significant association noted between the incidence of HE (31.2% vs. 25.0% p=0.06) or SBP (10.4% vs. 8.0% p=0.25) and in-hospital PPI use. There was also no significant association between PPI use and infectious complications, including bacteremia (8.6% vs. 7.6% p=0.63), pneumonia (12.7% vs. 12.5% p=0.95), urinary tract infections (9.2% vs. 6.6% p=0.19) and clostridium difficile (3.8% vs. 2.1% p=0.18). Patients on a PPI had greater in-hospital mortality (22.0% vs. 13. 5% p=0.002), although there was no significance between cause of death (p=0.31) nor death from infectious complications (18.5% vs. 23.1% p=0.52) between groups. Length of stay (LOS) was longer in patients exposed to PPI (median (IQR) 7 (4–17) vs 6 (3–13) p=0.03). Similar findings were noted on subgroup analysis of decompensated patients. Conclusions We did not observe a significant difference in HE, SBP or infectious complications among this cohort of cirrhotic patients by in-hospital PPI use. However, there was a significantly higher mortality rate noted in hospital and longer LOS, despite similar baseline MELD-Na and causes of death. Further study and judicious PPI prescribing practices in this vulnerable population of patients is warranted. Funding Agencies None

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A70 ASSOCIATION BETWEEN PROTON PUMP INHIBITOR USE IN HOSPITALIZED CIRRHOTICS AND DEVELOPMENT OF HEPATIC ENCEPHALOPATHY AND SPONTANEOUS BACTERIAL PERITONITIS

Journal of the Canadian Association of Gastroenterology ◽

10.1093/jcag/gwz047.069 ◽

2020 ◽

Vol 3 (Supplement_1) ◽

pp. 83-84

Author(s):

P Tan ◽

M Ukos ◽

C Miller ◽

J Lombardi ◽

E M Kelly

Keyword(s):

Hepatic Encephalopathy ◽

Proton Pump ◽

Variceal Bleeding ◽

Spontaneous Bacterial Peritonitis ◽

Relevant Information ◽

Prescribing Patterns ◽

Ulcer Disease ◽

Bacterial Peritonitis ◽

Significant Difference ◽

History Of

Abstract Background Proton pump inhibitors (PPI) are commonly prescribed medications which are indicated in various different gastrointestinal (GI) diseases, including peptic ulcer disease, gastroesophageal reflux disorder and upper GI bleeding. There is some evidence to suggest that PPI use in cirrhosis may predispose to the development of hepatic encephalopathy (HE) and spontaneous bacterial peritonitis (SBP), albeit with some controversy. Aims We aim to conduct a retrospective epidemiological analysis of the association between PPI use in hospitalized patients with cirrhosis, and prevalence of HE and SBP. Methods This was a retrospective cohort study of 600 adult patients (mean age 61.4 (SD=12.2)) admitted the Ottawa Hospital between January 1, 2011 and December 31, 2015 with cirrhosis. A chart review was conducted and relevant information extracted. Results Average MELD-Na on admission was 16.2 (sd=6.7). 14.8% of patients had a history of HE, 5.0% SBP, 7.8% with history of hepatocellular carcinoma and 1.0% with history of hepatorenal syndrome. 28.5% of patients had a history of varices, of which 11.0% had previous variceal bleeding. 69.3% of patients were on a PPI during their hospitalization. Not surprisingly, patients admitted with variceal bleeding were more likely to be exposed to PPI in hospital (97.2% vs 63.2%, p<0.01) Patients with a diagnosis of cirrhosis prior to index admission were more likely to be on a PPI in hospital (p=0.001) and on discharge (p=0.001). Patients with ascites were less likely to be on a PPI than those without ascites (64.1% vs 77.6%, p<0.01). There was no significant correlation between in hospital PPI use and MELD score (p=0.42). Amongst patients on PPI in hospital, 85.9% remained on a PPI at discharge. Although numerically greater, no statistically significant differences were observed in terms of prevalence of HE (21.3% in patients on PPI vs 8.3% in those not on PPI (p=0.37)), nor SBP (5.7% on PPI vs. 3.7% in those not on PPI (p=0.29)). Conclusions We did not observe a significant difference in HE and SBP among this cohort of cirrhotic patients by in-hospital PPI use. We did however note significantly higher PPI use in patients with previous diagnosis of cirrhosis as compared to those who were newly diagnosed, as well as those whose admissions were related to bleeding. Patients with ascites had lower prevalence of PPI use. Prescribing patterns for PPIs in patients with cirrhosis warrant further attention, including clinical utility and longer-term risks and benefits of this therapy. Funding Agencies None

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Determining the Risk of Spontaneous Bacterial Peritonitisdue to increase use of Proton Pump Inhibitors among cirrhotic patients with ascites

Pakistan Journal of Medical Sciences ◽

10.12669/pjms.37.4.3476 ◽

2021 ◽

Vol 37 (4) ◽

Author(s):

Bashir Ahmed Shaikh ◽

Zahid Ali Shaikh ◽

Aftab Hussain Shah ◽

Aneel Kumar

Keyword(s):

Proton Pump Inhibitors ◽

Proton Pump ◽

Spontaneous Bacterial Peritonitis ◽

Polymorphonuclear Neutrophil ◽

Retrospective Case ◽

Medical College ◽

Creative Commons ◽

Bacterial Peritonitis ◽

History Of ◽

Cirrhotic Patients

Objectives: The current study aimed to determine the Spontaneous Bacterial Peritonitis (SBP) risk due to increased use of Proton Pump Inhibitors (PPIs) among cirrhotic patients with ascites. Methods: This retrospective case-control study was conducted at Chandka Medical College & Hospital, Larkana from March 2013 to February 2014, involving 215 cirrhotic patients with ascites. Paracentesis was performed to distinguish cirrhotic patients with SBP and Polymorphonuclear Neutrophil (PMN) count ≥ 250 neutrophils/mm3 (cases) and non-SBP with PMN count < 250 neutrophils/mm3 (controls). The demographic details, history of PPIs use before admission and duration of Chronic Liver Disease (CLD) were inquired and statistical analysis was carried through SPSS Version 23.0. Results: Increased pre-hospital PPI intake was observed among cirrhotic patients with SBP (69.8%) as compared to those without SBP (48.8%; p = 0.014). The mean duration of PPI use was 19.16 ± 4.772 days, and it was more significant among older cirrhotic patients (p < 0.05). Increased duration of CLD was observed among PPI users, i.e. 20.47 ± 6.305 months vs. 18.95 ± 5.527 months among non-PPI users (p < 0.05). Conclusions: Our results show that cirrhotic patients with ascites consuming PPIs are more likely to develop SBP as compared to non-PPI users. doi: https://doi.org/10.12669/pjms.37.4.3476 How to cite this:Shaikh BA, Shaikh ZA, Shah AH, Kumar A. Determining the Risk of Spontaneous Bacterial Peritonitis due to increase use of Proton Pump Inhibitors among cirrhotic patients with ascites. Pak J Med Sci. 2021;37(4):---------. doi: https://doi.org/10.12669/pjms.37.4.3476 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Proton pump inhibitors as a risk factor for hepatic encephalopathy and spontaneous bacterial peritonitis in patients with cirrhosis with ascites

Hepatology ◽

10.1002/hep.28737 ◽

2016 ◽

Vol 64 (4) ◽

pp. 1265-1272 ◽

Cited By ~ 83

Author(s):

Gitte Dam ◽

Hendrik Vilstrup ◽

Hugh Watson ◽

Peter Jepsen

Keyword(s):

Risk Factor ◽

Hepatic Encephalopathy ◽

Proton Pump Inhibitors ◽

Proton Pump ◽

Spontaneous Bacterial Peritonitis ◽

Bacterial Peritonitis

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Faculty Opinions recommendation of Proton pump inhibitors as a risk factor for hepatic encephalopathy and spontaneous bacterial peritonitis in patients with cirrhosis with ascites.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.726588416.793561261 ◽

2019 ◽

Author(s):

Guadalupe Garcia-Tsao

Keyword(s):

Risk Factor ◽

Hepatic Encephalopathy ◽

Proton Pump Inhibitors ◽

Proton Pump ◽

Spontaneous Bacterial Peritonitis ◽

Bacterial Peritonitis

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Association between proton pump inhibitor use in hospitalized cirrhotics and development of hepatic encephalopathy and spontaneous bacterial peritonitis

Journal of Hepatology ◽

10.1016/s0168-8278(20)31955-3 ◽

2020 ◽

Vol 73 ◽

pp. S754

Author(s):

Pearl Tan ◽

Marissa Ukos ◽

Caragh Miller ◽

Julia Lombardi ◽

Erin Kelly

Keyword(s):

Hepatic Encephalopathy ◽

Proton Pump Inhibitor ◽

Proton Pump ◽

Spontaneous Bacterial Peritonitis ◽

Bacterial Peritonitis

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Are proton pump inhibitors a threat for spontaneous bacterial peritonitis and hepatic encephalopathy in cirrhosis? Not so fast

Hepatology ◽

10.1002/hep.28858 ◽

2016 ◽

Vol 65 (1) ◽

pp. 393-393 ◽

Cited By ~ 1

Author(s):

Muhammad Ali Khan ◽

George Cholankeril ◽

Colin W. Howden

Keyword(s):

Hepatic Encephalopathy ◽

Proton Pump Inhibitors ◽

Proton Pump ◽

Spontaneous Bacterial Peritonitis ◽

Bacterial Peritonitis

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Faculty Opinions recommendation of Association of proton pump inhibitor therapy with spontaneous bacterial peritonitis in cirrhotic patients with ascites.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.1160573.620941 ◽

2009 ◽

Author(s):

Waqar Qureshi

Keyword(s):

Proton Pump Inhibitor ◽

Proton Pump ◽

Spontaneous Bacterial Peritonitis ◽

Proton Pump Inhibitor Therapy ◽

Inhibitor Therapy ◽

Bacterial Peritonitis ◽

Cirrhotic Patients

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All-cause mortality and location of death in patients with established cardiovascular disease before, during, and after the COVID-19 lockdown: a Danish Nationwide Cohort Study

European Heart Journal ◽

10.1093/eurheartj/ehab028 ◽

2021 ◽

Cited By ~ 1

Author(s):

Jawad H Butt ◽

Emil L Fosbøl ◽

Thomas A Gerds ◽

Charlotte Andersson ◽

Kristian Kragholm ◽

...

Keyword(s):

Cardiovascular Disease ◽

Mortality Rate ◽

Hospital Mortality ◽

Location Of Death ◽

All Cause Mortality ◽

History Of ◽

Adjusted Incidence Rate ◽

Artery Disease ◽

Adjusted Incidence ◽

Overall Mortality

Abstract Background On 13 March 2020, the Danish authorities imposed extensive nationwide lockdown measures to prevent the spread of the coronavirus disease 2019 (COVID-19) and reallocated limited healthcare resources. We investigated mortality rates, overall and according to location, in patients with established cardiovascular disease before, during, and after these lockdown measures. Methods and results Using Danish nationwide registries, we identified a dynamic cohort comprising all Danish citizens with cardiovascular disease (i.e. a history of ischaemic heart disease, ischaemic stroke, heart failure, atrial fibrillation, or peripheral artery disease) alive on 2 January 2019 and 2020. The cohort was followed from 2 January 2019/2020 until death or 16/15 October 2019/2020. The cohort comprised 340 392 and 347 136 patients with cardiovascular disease in 2019 and 2020, respectively. The overall, in-hospital, and out-of-hospital mortality rate in 2020 before lockdown was significantly lower compared with the same period in 2019 [adjusted incidence rate ratio (IRR) 0.91, 95% confidence interval (CI) CI 0.87–0.95; IRR 0.95, 95% CI 0.89–1.02; and IRR 0.87, 95% CI 0.83–0.93, respectively]. The overall mortality rate during and after lockdown was not significantly different compared with the same period in 2019 (IRR 0.99, 95% CI 0.97–1.02). However, the in-hospital mortality rate was lower and out-of-hospital mortality rate higher during and after lockdown compared with the same period in 2019 (in-hospital, IRR 0.92, 95% CI 0.88–0.96; out-of-hospital, IRR 1.04, 95% CI1.01–1.08). These trends were consistent irrespective of sex and age. Conclusions Among patients with established cardiovascular disease, the in-hospital mortality rate was lower and out-of-hospital mortality rate higher during lockdown compared with the same period in the preceding year, irrespective of age and sex.

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