COMMENTARY

Top 11 Practice Changers in Gastroenterology: 2016

David A. Johnson, MD

Disclosures

December 28, 2016

Association of Proton Pump Inhibitors With Risk of Dementia: A Pharmacoepidemiological Claims Data Analysis

Gomm W, von Holt K, Thomé F, et al
JAMA Neurol. 2016;73:410-416

This article received a lot of press, and patients ask about this commonly, so it is very important for clinicians to understand the limitations of this study. A few previous studies[1,2] showed a link between the use of proton pump inhibitors (PPIs) and cognitive decline or dementia. Findings of mouse models in which the use of PPIs increased beta-amyloid levels in the brain are suggestive of a causal relation.[3] Elevated prevalence of these amyloid plaques are reported in patients with Alzheimer dementia.

These findings need to be interpreted with caution. This study lacks adjustment for well-recognized risk factors for dementia, in particular family history, heavy alcohol use, hypertension, and atherosclerosis. In addition, the proposed mechanism of harm of PPIs is elevation of beta-amyloid, which has been independently associated with Alzheimer dementia. However, only 2.5% of patients had this diagnosis. Further limitations include the use of diagnostic codes rather than validated instruments to establish the diagnosis of dementia and the lack of adjustment for the use of over-the-counter histamine-2 receptor antagonists—which have been linked to similar dementia risk in prior reports—or PPIs, both of which were available in Germany in 2003 and 2009, respectively.

Abstract

Long-Term Outcomes of Per-Oral Endoscopic Myotomy in Patients With Achalasia With a Minimum Follow-up of 2 Years: An International Multicenter Study

Ngamruengphong S, Inoue H, Chiu PW, et al
Gastrointest Endosc. 2016 Sep 20. [Epub ahead of print]

This is a retrospective review from international investigators in tertiary care centers who evaluated the long-term safety and efficacy of standard peroral endoscopic myotomy (POEM) for achalasia in 205 patients with a minimum follow-up of 2 years. Median follow-up was 31 months.

In addition to being a salvage therapy for other failed interventions, POEM should also be considered a first-line therapy option. Although I perform pneumatic dilation for type I and II achalasia, I now initially refer patients with type III achalasia for POEM. The longer myotomy achieved with POEM (typically 12-15 cm compared with < 8 cm with Heller myotomy) is much more effective in reducing recurring esophageal chest pain compared with pneumatic and surgical interventions.

Learning curve data[4] indicate that most operators require approximately 20 procedures to learn POEM and 40 to become efficient. Clinicians should be aware of this when making referrals.

Abstract

A Placebo-Controlled Trial of Obeticholic Acid in Primary Biliary Cholangitis

Nevens F, Andreone P, Mazzella G, et al; POISE Study Group
N Engl J Med. 2016;375:631-643

This study highlights the effectiveness of obeticholic acid, a selective farnesoid X receptor agonist. When used in addition to ursodiol, obeticholic acid improved values on liver tests in patients with primary biliary cholangitis. Clinicians should review the indications for supplementing traditional therapy with ursodiol. They should also note the diagnosis name change from "primary biliary cirrhosis" to "primary biliary cholangitis."

Abstract

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