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zoom RSS プロトンポンプ阻害剤による肺炎のリスク

<<   作成日時 : 2009/05/29 00:17   >>

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画像 入院患者に胃食道逆流を予防する薬剤をルーチンに投与することが増えている。集中治療を受ける患者のストレス潰瘍を予防するために Nexium,Prilosec,Prevacid といったプロトンポンプ阻害剤の使用が勧められ、安全だと広く認められており多くの病院で投与されている。入院患者の40-70%、初回入院では半数が制酸剤を
投与されていると推計されている。
 胃酸を抑制するプロトンポンプ抑制剤が胃腸管と気道の上部で違うタイプの細菌の成長を促進する可能性があり、そうした細菌が肺炎の原因の可能性がある。また、別の説明として、酸が刺激となり咳を誘発する可能性があるが、咳き込みが弱くなれば肺炎が促進される可能性がある。
 2004年1月1日から2007年12月31日にBeth Israel Deaconessに入院した63,878人を分析した。ICUではない病室に3日以上入院した患者で、半数以上に制酸剤が投与されていた。投与された患者は投与されなかった患者の2倍以上肺炎になった(4.9% : 2 %)。最初から病気だった患者などを補正した後で、制酸剤投与により肺炎リスクが30%増加していると結論された。肺炎の増加は、Pepcid, Zantac のようなヒスタミン2受容体阻害剤の制酸剤では見られなかった。
 以前の研究で、プロトンポンプ阻害剤が、地域感染型の肺炎・股関節の骨折・Clostridium difficile下痢症と関連していると報告されている。
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Some Acid-Reflux Drugs Are Linked to Pneumonia
http://www.nytimes.com/2009/05/27/health/27drugs.html

By RONI CARYN RABIN
Published: May 26, 2009

A growing number of hospital patients are routinely given drugs to prevent acid reflux. But a new study has found that patients who take these so-called proton pump inhibitors are at higher risk for pneumonia than those who do not.

The drugs ― including Nexium, Prilosec and Prevacid ― are often recommended for intensive-care patients to prevent stress ulcers, and in recent years they have been given to many other hospital patients, in large part because they are widely perceived to be safe. Experts estimate that 40 to 70 percent of inpatients now receive acid-suppressive drugs during a hospital stay, with about half receiving them for the first time.

“I noticed that there were a lot of patients being placed on these for prophylactic purposes, and I thought that was curious, because they are not currently recommended for patients who aren’t at high risk for stress ulcers,” said the study’s lead author, Dr. Shoshana J. Herzig, chief medical resident at Beth Israel Deaconess Medical Center in Boston, explaining why she was interested in the subject.

Dr. Herzig said proton pump inhibitors, which suppress acid in the stomach, might promote the growth of different types of bacteria in the upper gastrointestinal and respiratory tract, and those bacteria may be the culprits in the pneumonias. Another explanation, she suggested, may be that acid stimulates coughing, and coughing less may promote pneumonia.

The study, published in this week’s issue of The Journal of the American Medical Association, analyzed 63,878 admissions to Beth Israel Deaconess from Jan. 1, 2004, to Dec. 31, 2007. All of the records analyzed belonged to adults hospitalized for three days or more, who had not been in intensive care. Acid-suppressive drugs were ordered for just over half of the patients.

Among patients who received the drugs, 4.9 percent developed pneumonia in the hospital ― more than double the 2 percent who had not been given the drugs. After adjusting the figures to account for the fact that recipients of the drugs may have been sicker to begin with, the researchers determined that patients treated with acid-reflux drugs faced a 30 percent increase in pneumonia risk over patients who were not.

The increase in pneumonia was not seen among patients who took a different type of acid-reflux drug, the so-called histamine-2 receptor antagonists, sold under names like Pepcid and Zantac.

A spokesman for AstraZeneca, which makes Nexium, also known as “the purple pill,” said the study had limitations and could not definitively demonstrate that the drug caused excess pneumonia.

Earlier reports have linked proton pump inhibitors to other complications, including community-acquired pneumonia, hip fractures and diarrhea associated with Clostridium difficile.

Although the drugs are used to prevent stress ulcers, “a lot of people don’t need to be on them in the first place, and they’re sent home on them and stay on them,” said Dr. Joel J. Heidelbaugh, an assistant professor of family medicine at the University of Michigan. He added that such inappropriate use of the drugs drove up health care costs.
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Acid-Suppressive Medication Use and the Risk for Hospital-Acquired Pneumonia

Shoshana J. Herzig, MD; Michael D. Howell, MD, MPH; Long H. Ngo, PhD; Edward R. Marcantonio, MD, SM

JAMA. 2009;301(20):2120-2128.

Context The use of acid-suppressive medication has been steadily increasing, particularly in the inpatient setting, despite lack of an accepted indication in the majority of these patients.

Objective To examine the association between acid-suppressive medication and hospital-acquired pneumonia.

Design, Setting, and Patients Prospective pharmacoepidemiologic cohort study. All patients who were admitted to a large, urban, academic medical center in Boston, Massachusetts, from January 2004 through December 2007; at least 18 years of age; and hospitalized for 3 or more days were eligible for inclusion. Admissions with time spent in the intensive care unit were excluded. Acid-suppressive medication use was defined as any order for a proton-pump inhibitor or histamine2 receptor antagonist. Traditional and propensity-matched multivariable logistic regression were used to control for confounders.

Main Outcome Measure Incidence of hospital-acquired pneumonia, defined via codes from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), in patients exposed and unexposed to acid-suppressive medication.

Results The final cohort comprised 63 878 admissions. Acid-suppressive medication was ordered in 52% of admissions and hospital-acquired pneumonia occurred in 2219 admissions (3.5%). The unadjusted incidence of hospital-acquired pneumonia was higher in the group exposed to acid-suppressive medication than in the unexposed group (4.9% vs 2.0%; odds ratio [OR], 2.6; 95% confidence interval [CI], 2.3-2.8). Using multivariable logistic regression, the adjusted OR of hospital-acquired pneumonia in the group exposed to acid-suppressive medication was 1.3 (95% CI, 1.1-1.4). The matched propensity-score analyses yielded identical results. The association was significant for proton-pump inhibitors (OR, 1.3; 95% CI, 1.1-1.4) but not for histamine2 receptor antagonists (OR, 1.2; 95% CI, 0.98-1.4).

Conclusions In this large, hospital-based pharmacoepidemiologic cohort, acid-suppressive medication use was associated with 30% increased odds of hospital-acquired pneumonia. In subset analyses, statistically significant risk was demonstrated only for proton-pump inhibitor use.


Author Affiliations: Divisions of General Medicine and Primary Care (Drs Herzig, Ngo, and Marcantonio), Pulmonary and Critical Care (Dr Howell), and Gerontology (Dr Marcantonio), Beth Israel Deaconess Medical Center, Boston, Massachusetts; and Harvard Medical School, Boston (Drs Herzig, Howell, Ngo, and Marcantonio).


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プロトンポンプ阻害剤による肺炎のリスク 医師の一分/BIGLOBEウェブリブログ
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