Caught Between A Rock And A Hard Place - Part 7

It's deja vu all over again

- Yogi Berra

So here I am, safely ensconced back home again, having returned from a week inside the San Diego Convention Center where the American Academy of Family Physicians held its annual Congress of Delegates followed by its annual Scientific Assembly. I'm trying again to desperately catch up on my reading & paperwork before the patient care starts up again later today. Then I stumbled upon a retrospective cohort study published earlier this month in the British Medical Journal in which the authors concluded that using proton pump inhibitors to attempt to prevent stress ulcers in coronary artery bypass graft patients was associated with an unintended consequence of post-operative pneumonia.

But didn't I just write about PPIs recently? Turns out I did discuss some harms associated w/PPIs just 11 days ago in response to a study to be published in next month's issue of the Mayo Clinic Proceedings. But to show you that medicine is not always so clear cut, a population-wide retrospective cohort study was published over 3 years ago in this very same BMJ in which the authors came to a diametrically opposed conclusion: there was no link between PPI use and post-operative pneumonia.  

Which begs the question: what do I/you do? Well, when it comes down to conflicting studies, we believe more strongly in the double-blind, placebo-controlled trial which demonstrates cause & effect, whereas as retrospective cohort & other observational studies only demonstrate an association but can't tell what caused what, if indeed one thing caused another. In this particular case, both studies are retrospective cohort studies, so that doesn't help us.

So let's take a look at the bigger issue. Use of PPIs is linked to multiple other unintended consequences as I pointed out in Part 6. Based upon that, I see no reason to take a PPI w/o good reason based upon one study that found no harm given the many others that did. Remember, first, do no harm. Primum non nocere.

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