Publication Date 01/02/2010         Volume. 2 No. 1   
Information to Pharmacists


From the desk of the editor

Welcome to the February 2010 edition of i2P – Information to Pharmacists E-Magazine.

It has been extremely hot and humid in northern NSW where this publication is put together, and I can assure you that this weather has made it quite difficult to concentrate on this production.
But I have finally arrived at the transmission point, and we do have a range of interesting news and opinion items for you this month.

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PPI's create multiple nutritional problems.

Staff Writer

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Editing and Researching news and stories about global and local Pharmacy Issues

Over the years with a few hundred home medicines reviews under my belt, I have consistently noted the large number of proton pump inhibitors (PPI's) that have been mindlessly prescribed by doctors. Patients have been shunted into thinking that taking a PPI must now be a permanent part of their lifestyle - they are too frightened to come off treatment because they usually have "the mother of all" reflux attacks.
In a sense, they have become medical addicts.
Anyone who has gained a qualification in clinical nutrition knows that without hydrochloric acid in the stomach, proper digestion, and breakdown of proteins in particular, is not possible.
Also, the flow of food from the stomach to the duodenum is impaired when low concentrations of hydrochloric acid exist.
One PPI dose can inhibit hydrochloric acid secretion for up to 36 hours.
The consequence of this is that with impaired food flows, fermentation begins to occur as food remains too long in the stomach and that encourages overgrowth of bacteria, plus the production of acids that are not normally present in the stomach.
Peristalsis develops a faulty stop/go rhythm and food toxins are able to attack the cells of the intestinal tract, setting in place the potential for diverticulitis, polyp formation and stomach and bowel cancers.
Altered intestinal flora thrive on a range of improperly digested foods creating gas, pain and discomfort. With insufficient amino acid being the result of improper digestion, a range of mineral deficiencies begin to occur.
Minerals are unable to chelate appropriately with a specific amino acid because there is insufficient to maintain a health balance.
These "carrier" protein complexes are efficiently absorbed through the intestinal wall.
Oil soluble vitamins also need amino acids for absorption through the intestinal wall.
Vitamin B12 also is inefficiently absorbed with low stomach acid, which can lead to a range of anaemias.

Most GERD sufferers probably sought medical treatment at a time when their acid secretion was low, setting up a range of symptoms that might have been better treated with an actual supplement of hydrochloric acid (usually in the form of betaine).

It is obvious that if PPI's are to be used in any capacity, they should be used with care and only intermittently.
With one form of PPI set to rescheduled as an over-the-counter product, pharmacists may need to intervene if sales of these products indicate overuse.
A strategy designed to wean patients off their PPI's needs to be developed and appropriately supervised.
In my mind, services of this type should be remunerated in some way, because of the eventual savings for the PBS - a case for the independent paid professional services pharmacist.
The following story from Medscape provides evidence for this problem.

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Small Intestinal Bacterial Overgrowth Common Among Long-Term PPI Users

Source: Medscape

NEW YORK (Reuters Health) Jan 21 - In patients with gastroesophageal reflux disease (GERD), long-term use of proton pump inhibitors (PPI) contributes to bacterial overgrowth in the small intestine, new research from Italy shows.

Small intestinal bacterial overgrowth, in which the small bowel is colonized by large numbers of bacteria ordinarily found in the colon, produces bloating, diarrhea and other symptoms, the researchers explain.

Led by Dr. Lucio Lombardo, of the Mauriziano U.I. Hospital in Torino, the investigators used glucose hydrogen breath tests to look for small intestinal bacterial overgrowth in 450 consecutive patients enrolled in three groups:

-- 200 GERD patients treated with PPIs for a median of 36 months;

-- 200 patients with irritable bowel syndrome (IBS) who had not used PPIs for at least 3 years; and

-- 50 healthy controls who had not used PPIs for at least 10 years.

"The rationale for using IBS as 'pathologic' control stands on the large prevalence of small intestinal bacterial overgrowth in IBS patients and the overlapping of symptoms between the two clinical conditions," the authors said.

According to their article published online in Clinical Gastroenterology and Hepatology, they found small intestinal bacterial overgrowth in 50% of the PPI users with GERD, 24.5% of the IBS patients, and 6% of the healthy controls. There were significant differences in prevalence between GERD/PPI patients and the IBS patients (odds ratio = 3.14; p < 0.001), between GERD/PPI patients and controls (OR = 16.0; p < 0.001), and between IBS patients and controls (OR = 6.12; p < 0.005).

All subjects with small intestinal bacterial overgrowth were given high-dose rifaximin for 2 weeks. Treatment was successful in 87% of cases in the PPI group and in 91% of cases in the IBS group.

The authors suggest that PPI-related small intestinal bacterial overgrowth may be under-diagnosed because the symptoms overlap with those of other gastrointestinal disorders.

They point out that while the glucose hydrogen breath test only indirectly detects the condition, it's noninvasive and reproducible, whereas the current standard -- aspiration of duodenal-jejunal content for culture -- is not.

However, they add, the "gold standard for the diagnosis of small intestinal bacterial overgrowth is yet to be defined."

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