Replying to Jon H. 11/11/2023 - 14:25
Thanks Jon.
You make some brilliant points! Thank you for highlighting that there is often not a very right or very wrong answer when it comes to decision making around these drugs… particularly omeprazole!
I totally agree, omeprazole is not a benign drug! Proton pump inhibitors (PPI) have a number of side effects. Small intestinal bacterial overgrowth is an adverse consequence of chronic PPI administration in people. Proton pump inhibitors increased survival of swallowed bacteria in the upper GI tract by decreased intestinal peristalsis, decreased gastric emptying, changes in epithelial mucus composition, increased pH, and increased bacterial translocation. Increased growth of bacteria in the upper GI tract may increase the risk of bacterial aspiration pneumonia.
Bacterial overgrowth can have deleterious consequences when PPIs are administered with other drugs that can injure the small intestinal (SI) mucosa. It is common to prescribe PPIs in patients at risk for upper GI injury from nonsteroidal anti‐inflammatory drugs (NSAIDs), but PPIs can alter the SI microbiome, increasing the risk of injury to the intestinal epithelium caused by NSAIDs. This effect is acid‐independent and unrelated to gastric mucosa injury caused by NSAIDs. Inhibition of intestinal cyclooxygenase 1 and 2 (COX‐1, COX‐2) enzymes injures the SI mucosa. Enterohepatic recycling of NSAIDs likely plays a role whereby high concentrations of NSAIDs in bile are secreted into the duodenum in close proximity to the major duodenal papilla. Some of the most serious intestinal lesions in dogs caused by NSAIDs occur in this region. Small intestinal injury may be caused by increased numbers of gram‐negative facultative anaerobic bacteria that flourish in the SI of patients treated with PPIs. Lesions are characterized by loss of villi, erosions, and multifocal ulcers distributed throughout the small bowel. Anaemia also may occur. Whereas some bacteria play a protective role against intestinal mucosal injury by NSAIDs, the intestinal dysbiosis arising from PPI administration increases the risk of NSAID‐induced intestinal injury.
Lots to think about!
Scott 🙂
