PPI use & IBD outcomes

April 6, 2021

Issue 07

Clinical Question

Does PPI use affect outcomes in IBD patients receiving infliximab?

Editor’s Bottom Line

Proton pump inhibitors are associated with worse outcomes when patients with IBD are treated with infliximab. However, this difference is more likely to reflect residual confounding than a true causal relationship.

Reference

Lu TX, Dapas M, Lin E, et al. The influence of proton pump inhibitor therapy on the outcome of infliximab therapy in inflammatory bowel disease: a patient-level meta-analysis of randomised controlled studies. Gut. Epub ahead of print Dec 17, 2020; http://dx.doi.org/10.1136/gutjnl-2020-321609

Synopsis

Recent studies have suggested that proton pump inhibitor (PPI) use may impact treatment efficacy and disease outcomes in patients with IBD. To document the relationship between PPI use and outcomes in infliximab-treated IBD patients, researchers at the University of Chicago and elsewhere examined data from five large randomized controlled trials, including 1,036 patients with moderate-to-severe IBD treated with infliximab, 147 of whom also received PPIs.

Patients who received concomitant PPI therapy were significantly older than those who did not (44 vs. 37 years of age for PPI and no PPI, respectively; p<0.001), were more likely to be white (98% vs. 92%, respectively; p=0.01) and were less likely to receive an immunomodulator (18% vs. 36%, respectively; p<0.001).

After adjusting for baseline patient characteristics, the authors showed that 30% of those receiving a PPI were in remission after 30 weeks of infliximab treatment, compared to 49% of those not receiving a PPI (p<0.001). Analyses controlling for age, sex, race, smoking status, immunomodulator use, history of intestinal resection and infliximab dose confirmed that the odds of attaining remission at 30 weeks were significantly lower among PPI users (Odds Ratio: 0.45; p<0.001). This association was significant among patients with Crohn’s disease (CD) but not those with ulcerative colitis (UC).

At 54 weeks, 34% and 64% of CD patients using or not using PPIs, respectively, achieved remission (p<0.001). There were no significant differences in remission rates at week 54 for UC patients using or not using PPIs.

PPI use was associated with significantly higher rates of hospitalization in both CD patients (13% vs. 8%; p=0.161) and UC patients (19% vs. 8%; p=0.021). There were no differences in rates of adverse events associated with PPI use.

Details

Study Design: Meta-analysis

Funding: National Institutes of Health

Allocation: None

Setting: Multicenter

Level of Evidence: 1a