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

The new findings’ data were gathered through an online survey, which involved 1007 Indian HCPs (health care professionals) from different zones of India (South N=322, West N=322, East N=184, and North N=179). Subsequently, the survey results were discussed during four PAN India round table meetings. The survey questions included 12 questions.

The study was published in the December (2023) Issue of the Journal of Association of Physicians of India.

The key results from this study are as follows:

• On an upbeat note, a majority of the HCPs (91%) reported that the long-term use of PPIs disturbs the GI flora; the recognition aligns with the growing concern over the consequences of prolonged PPI administration.
• A significant proportion of contributors/ HCPs, 62.66% agreed and 27.01% strongly agreed, believed that co-prescribing pre- and probiotics with a PPI can lead to favourable outcomes and ultimately improve the overall quality of life (QoL).
• About 49.65% of contributors also consider that pre- and probiotics will exert clinical improvement when co-prescribed with PPIs from 1 to 4 weeks. This indicates a positive outlook on the therapeutic effects of this prescribing pattern in managing various GI issues associated with PPIs and its potential to enhance overall patient well-being.
• Approximately 55% of HCPs reported considering the co-prescription of PPI with pre- and probiotics for more than 3 months to prevent GI disturbances and 35.5% of HCPs opined that it is needed for more than 1 month. This approach could facilitate probiotic colonization and counteract the microbial perturbation induced by PPIs.
• The majority of the HCPs (71.30%) also reported that the most common suggestive current practice is patient-centric co-prescription of PPI and PPBs (pre and probiotics). Majority of the HCPS (67.92%) also suggest using PPI along with PPBs in patient-centric co-prescription is ideal, followed by universal co-prescription (26.81%)

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.