Scope of Pre-probiotics as Add-On to PPIs in Different Clinical Indication: 1000+ Indian HCPs Opine

Prescription Pattern of Proton Pump Inhibitors (PPIs):

Overall, 43.40% of the HCPs participated in the survey prescribed PPI in 10-30% of their patients for 3-6 months, while 27.31%, 23.44%, and 5.86% mentioned that <10, 30–50, and 50–70% of their patients received PPIs for 3–6 months.

The majority of the HCPs (70.90%) reported that long-term PPI use is most commonly used for the prophylaxis against GERD-induced gastritis, followed by peptic ulcer disease (58.39%), gastroparesis (46.47%), prophylaxis for nonsteroidal anti-inflammatory drug (NSAID)-induced gastritis (45.40%), and in irritable bowel syndrome (IBS) (41.11%).

Clinical Issues with Long-Term Use of PPIs

Abnormal bowel habits, as per 63.65% of the HCPs, were the most commonly reported symptoms with long-term use of PPI, followed by bloating (49.65%), micronutrient deficiencies (46.28%), flatulence (44.69%), and abdominal pain and discomfort (41.41%). This demonstrates that long-term use of PPIs can disrupt the balance of gut microbiota, increasing vulnerability to infections and intestinal diseases. The high prevalence of abnormal bowel habits and various digestive symptoms associated with long-term PPI use underscores the importance of monitoring and managing these side effects to ensure optimal patient care and treatment outcomes.

Prescription Pattern of Pre and Probiotics:

Antibiotic-associated diarrhea (AAD) (78.05%) was the most preferred indication for using pre-and probiotics, followed by acute infectious diarrhea (62.07%), inflammatory bowel disease (IBD)/IBD-like symptoms (51.64%), diabetes mellitus (28.7%), and hepatic encephalopathy (18.67%). This suggests that probiotics can be safely used in various conditions, serving as a co-prescription alongside certain medications, particularly in diabetes, hypertension, and coronary artery disease. Their consideration is even more pronounced for individuals taking PPIs and those with metabolic syndrome. It also indicated that incorporating pre- and probiotics alongside antibiotics can help reduce the incidence and severity of diarrhea by promoting beneficial microbial populations and inhibiting the growth of harmful bacteria.

Five Commandments from the Study:

Based on the survey results, panellists recommended five commandments summarized here

1. Perform a thorough clinical evaluation before prescribing PPIs (level 1, more than 50% HCPs agreed).

2. Prescribe PPIs for a short-term duration (≤8 weeks). If long-term therapy is prescribed, reassess the need for continuation periodically and attempt to taper or discontinue if possible (level 2, 30-50% HCPs agreed).

3. Educate patients about the potential side effects associated with long-term PPI use, especially regarding abnormal bowel habits, bloating, micronutrient deficiencies, flatulence, and abdominal pain (level 2, 30-50% HCPs agreed).

4. Co-prescribe pre- and probiotics with PPIs when managing patients with AAD, and in patients experiencing abnormal bowel habits, bloating (level 1, more than 50% HCPs agreed), micronutrient deficiencies, flatulence, and abdominal pain (level 2, 30-50% HCPs agreed).

5. Consider co-prescribing pre- and probiotics for >3 months to achieve favorable outcomes and improve overall QoL (level 1, more than 50% HCPs agreed) while monitoring and assessing their effectiveness regularly.

A considerable proportion of Indian healthcare professionals (HCPs) acknowledged the negative impact of long-term PPI use on GI flora. Contributors agreed that co-prescribing pre- and probiotics with PPIs could provide positive results, improving overall QoL. This study gives useful insights to help clinical decision-making and improve patient care by bridging the gap between research and practice.

Reference:

Kalra S, Joshi A, Tiwaskar M, et al. The Scope of Pre- and Probiotics as an Add-on to Proton-pump Inhibitors in Various Clinical Indications. J Assoc Physicians India 2023;https://doi.org/10.59556/ japi.71.0409.