When to choose H2 blockers over PPI's?

[nickolas]

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I am sure there are a couple of cases PPI's are contraindicated. Is there any other reason other than P450 interactions?

 

[Nivakia]

PPIs are bad for you on so many levels

 

[Crayola227]

I thought there was something about B vitamin deficiency cropping up in elderly people after a few yrs on it, although I think that is related to decreased pH & so is true of all those meds, but I know it's purportedly worse with PPIs
all I got for ya sorry

 

[Crayola227]

PPIs are bad for you on so many levels

Please don't.

 

[Crayola227]

you know what's really bad for you?
GI bleeding (just saw one from no ppx, assuming you know what ppx means)
Esophageal cancer
Esophageal strictures
Asthma exacerbations

 

[FrisbeeDocIM]

you know what's really bad for you?
GI bleeding (just saw one from no ppx, assuming you know what ppx means)
Esophageal cancer
Esophageal strictures
Asthma exacerbations

Yes, PPIs are great medications, but are also overused (and I don't know the person you're replying to, but it's a bit pretentious to assume someone doesn't know what ppx stands for...). Osteoporosis, C diff infections, AIN, and many other side effects abound. They're excellent when indicated, but like many medications, inappropriate to continue indefinitely for most patients.

As for the OP: H2RAs are still generally cheaper (although generic omeprazole/esomeprazole is getting close to the same price), so being on the $4 list may play a factor.

 

[NontradICUdoc]

there is some evidence that PPIs increase the risk for the development of a significant infection due to the lost nature of the low pH. However the risk of this development is low. In addition there is some decrease in the effectiveness of medications like Plavix when taken together with a PPI, again due to the rise in the pH of the gastric secretions. However, each of these need to be taken on a case by case basis.

 

[Crayola227]

Yes, PPIs are great medications, but are also overused (and I don't know the person you're replying to, but it's a bit pretentious to assume someone doesn't know what ppx stands for...). Osteoporosis, C diff infections, AIN, and many other side effects abound. They're excellent when indicated, but like many medications, inappropriate to continue indefinitely for most patients.

As for the OP: H2RAs are still generally cheaper (although generic omeprazole/esomeprazole is getting close to the same price), so being on the $4 list may play a factor.

it's pretentious for someone with status "Non-student" with 64 mssgs joined in 3/15 to pop in w/ nothing besides "bad for you on so many levels."
it's not pretentious to assume this person who is offering essentially zero information not even anything to their ill-stated opinion doesn't know what prophylaxis is. I pointed that out because as I was typing I became aware of the irony that who I was responding to likely had no basis for understanding what I was even typing

I never came in here and said they were perfect wonder drugs.... just don't appreciate the anti-medicinal mongering that abounds in popular society these days
any automatic statement re: a medication that amounts to "is bad for you on so many levels" w/ no further explanation gets an automatic "you sound like an ignorant idiot" from me until something more intelligent is offered

on another note, thank you your post was very informational indeed

 

[Crayola227]

As for the OP: H2RAs are still generally cheaper (although generic omeprazole/esomeprazole is getting close to the same price), so being on the $4 list may play a factor.

right and to OP as I understand it pricing and changes in Rx vs OTC set up a situation where you started a patient on H2 blockers to see if you could get by with that & switched to PPI if that was ineffective as PPIs are more effective but were expensive and only Rx

now that money and OTC status has changed, given the interactions of H2 blockers, more docs are asking themselves why don't we just cut to the more effective less interactions med right off the bat

so a lot of the "advantages" of H2 blockers has gone away so now PPIs are being used more heavily/first line
in fact, a lot of GI tell me to do just that, and that's what I do

 

[jdh71]

you know what's really bad for you?
GI bleeding (just saw one from no ppx, assuming you know what ppx means)
Esophageal cancer
Esophageal strictures
Asthma exacerbations

Actually no good evidence linking asthma exacerbations and reflux in adults.

 

[jdh71]

I use H2 blockers for ICU GI prophylaxis in intubated patients when they don't carry a diagnosis of "GERD" coming in and PPI when patients do.

PPIs do confer a higher risk for ventilator associated pneumonia, at least in post surgical patients (and I don't see why not in MICU patients), so if I don't need to use them I don't.

 

[Crayola227]

Gosh, I dunno. Thanks for the headsup about the asthma and PPI thing.

In general though,
I'll just leave it at the idiotic rules of thumb I live by:
if ENT or lung problems, think about belly acid
thinking can't hurt (or can it...?)

I've seen chronic cough, hoarseness, recurrent sinus infections, chronic bronchitis, and asthma all improve with GERD-style tx (lifestyle mods included of course) including PPI. Anecodotal? Sure. I did just review the topic tho to be a bit less so

https://my.clevelandclinic.org/heal...ogeal_reflux_disease_GERD/hic_GERD_and_Asthma
citations from 2013 at least

sorta old but was a comprehensive review I found from a good journal
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2714564/
Ann Thorac Med. 2009 Jul-Sep; 4(3): 115–123.
doi: 10.4103/1817-1737.53347
PMCID: PMC2714564
Pulmonary manifestations of gastroesophageal reflux disease

this last one is just fascinating
J Transl Med. 2015; 13: 249.
Published online 2015 Aug 1. doi: 10.1186/s12967-015-0614-x
PMCID: PMC4522053
Pleiotropic effect of the proton pump inhibitor esomeprazole leading to suppression of lung inflammation and fibrosis
Yohannes T Ghebremariam,

John P Cooke, William Gerhart, Carol Griego, Jeremy B Brower, Melanie Doyle-Eisele, Benjamin C Moeller, Qingtao Zhou, Lawrence Ho, Joao de Andrade, Ganesh Raghu, Leif Peterson, Andreana Rivera, and Glenn D Rosen

You all bring up good points on the dangers of PPIs, I think for the most part when a PPI is called for it's a no brainer. They are some of the best drugs we have as far as efficacy, SE profile, interactions, and addresses one of the most common and troublesome conditions around in a very safe way. I get that there are exceptions to every rule, and for anything common with a seemingly "great" treatment, at some point the pendulum is going to swing the other way and it's going to be overused and all the downsides are going to be much more apparent.

I mean, yeah, I don't treat asthma with a PPI off hand, and I see patients with it on their med list for no good reason who tell me they've never had reflux or a bleed, on baby aspirin (not a good enough reason on its own).

I will say that I am fairly young, was taking a reasonable dose of NSAID, with no PPI and not long ago was hospitalized for a seemingly random lifethreatening GIB (no IBD). That's cool though. GI gave me the go ahead for NSAID therapy sans PPI ppx after a clean scoping. Now that was a surprise.

I feel empowered to be more picky in Rx'ing them now.

 

[buonassezia]

I use H2 blockers for ICU GI prophylaxis in intubated patients when they don't carry a diagnosis of "GERD" coming in and PPI when patients do.

PPIs do confer a higher risk for ventilator associated pneumonia, at least in post surgical patients (and I don't see why not in MICU patients), so if I don't need to use them I don't.

Yes, we tend to do this in our MICU, as well. There's also good evidence for higher risk of C diff colitis with PPIs.