Are children with cystic fibrosis who are treated with a proton-pump inhibitor at risk for vitamin B(12) deficiency?

Vitamin B12 deficiency and use of proton pump inhibitors: a systematic review and meta-analysis

BACKGROUND

Proton pump inhibitors (PPI) may impact the absorption of vitamin B12. We performed a systematic review to ascertain if PPI use increases risk of vitamin B12 deficiency.

METHODS

Electronic databases (Pubmed, Embase, Scopus) were searched on first of September 2022. We selected studies that compared the frequency of vitamin B12 deficiency in PPI users and non-users. Pooled Odds Ratio (OR) was calculated for the occurrence of vitamin B12 deficiency in PPI users compared to non-users. The risk of bias was assessed using the Newcastle Ottawa scale.

RESULTS

Twenty-five studies were included. The pooled OR of vitamin B12 deficiency among PPI users (2852 participants) was higher than non-users (28070 participants) (OR 1.42, 95% CI: 1.16-1.73; I² = 54%). Overall risk of PPI use among vitamin B12 deficient individuals was higher than those without deficiency (OR 1.49, 1.20-1.85; I² = 68%). Most studies found no difference between serum vitamin B12 levels among PPI users compared to non-users.

CONCLUSION

Although the pooled OR of vitamin B12 deficiency was slightly increased in PPI users, but there was significant heterogeneity, and the pooled OR was too low to imply an association clearly. Better-designed prospective studies in long-term users may clarify the issue.

REGISTRATION

This study was not registered on PROSPERO.

Proton-pump inhibitors adverse effects: a review of the evidence and position statement by the Sociedad Española de Patología Digestiva

INTRODUCTION

In the last few years a significant number of papers have related the use of proton-pump inhibitors (PPIs) to potential serious adverse effects that have resulted in social unrest.

OBJECTIVE

The goal of this paper was to provide a literature review for the development of an institutional position statement by Sociedad Española de Patología Digestiva (SEPD) regarding the safety of long-term PPI use.

MATERIAL AND METHODS

A comprehensive review of the literature was performed to draw conclusions based on a critical assessment of the following: a) current PPI indications; b) vitamin B12 deficiency and neurological disorders; c) magnesium deficiency; d) bone fractures; e) enteric infection and pneumonia; f) interactions with thienopyridine derivatives; e) complications in cirrhotic patients.

RESULTS

Current PPI indications have remained unchanged for years now, and are well established. A general screening of vitamin B12 levels is not recommended for all patients on a PPI; however, it does seem necessary that magnesium levels be measured at therapy onset, and then monitored in subjects on other drugs that may induce hypomagnesemia. A higher risk for bone fractures is present, even though causality cannot be concluded for this association. The association between PPIs and infection with Clostridium difficile is mild to moderate, and the risk for pneumonia is low. In patients with cardiovascular risk receiving thienopyridines derivatives it is prudent to adequately consider gastrointestinal and cardiovascular risks, given the absence of definitive evidence regardin potential drug-drug interactions; if gastrointestinal risk is found to be moderate or high, effective prevention should be in place with a PPI. PPIs should be cautiously indicated in patients with decompensated cirrhosis.

CONCLUSIONS

PPIs are safe drugs whose benefits outweigh their potential side effects both short-term and long-term, provided their indication, dosage, and duration are appropriate.

Cobalamin status in children

Cobalamin and the metabolic markers methylmalonic acid and total homocysteine undergo marked changes during childhood. In breastfed infants a metabolic profile indicative of cobalamin deficiency is common. Symptoms of cobalamin deficiency in children differ with age, presenting a continuum from subtle developmental delay to life-threatening clinical conditions. The symptoms may be difficult to detect, particularly in infants, and there tends to be a diagnostic delay of several months in this age group. Several reports show that even moderate deficiency in children may be harmful, and long-term consequences of neurological deterioration may persist after cobalamin deficiency has been treated. Given the crucial role of cobalamin for normal growth and development, possible widespread infantile deficiency needs attention. Cobalamin deficiency should be considered a differential diagnosis in children with subtle symptoms, and strategies to prevent cobalamin deficiency in mothers and children should be addressed.

Long-term proton pump inhibitor use in children: a retrospective review of safety

The objective of this work was to assess the efficacy of continuous proton pump inhibitor (PPI) therapy in children and to evaluate changes in biochemical, endoscopic, and histologic parameters during such treatment. A retrospective review of children receiving PPI therapy continuously for 1 year or more with baseline and follow-up esophageal and gastric biopsies on treatment was conducted to assess type, frequency, and duration of PPI dosing, symptom relief, gastrin levels, histologic findings, and adverse events. A total of 113 children (59 male, median age 4.5 years) were identified. Of these, 31% (35/113) were neurologically impaired. The median treatment duration was 35.2 months. Elevated serum gastrin levels occurred in 73% of children with no statistically significant differences in gastrin level by PPI type, dose, and dosing frequency or treatment duration. Adverse events were reported by 12% of children: diarrhea (5%) and constipation (4%) were the most frequent. Long-term PPI therapy appears to be effective, safe and well tolerated in children despite some biochemical, endoscopic, and histologic changes.

Inhibidores de la bomba de protones en pediatría

In last years the use in the pediatric area of proton pump inhibitors (omeprazole, lansoprazole, pantoprazole, rabeprazole and esomeprazole) is more often, nevertheless the clinical trials carried out are poor. The aim of this work is to analyse the bibliography published about this kind of drugs in children and to make a revision of its use in the last seven years. More studies with omeprazole and lansoprazole have been developed, to be exact omeprazole and lansoprazole is present in 122 bibliographic appointments and 34 for lansoprazole, which include studies that demonstrate a good tolerance and efficacy. The remaining proton pump inhibitors count with very few studies. The main therapeutic indications were the eradication of Helicobacter pylori, gastroesophageal reflux disease and esophagitis. The number of patients included in the reviewed studies is quite heterogeneous, from 8 to 122 and the age range between 8 days and 17 years. On the other hand, it could be highlighted the non-existence of formulations adapted to the pediatric population and the difficulty of administration specially in the youngest patients. As in many other drugs, it would be necessary to carry out clinical trials in order to determinate the pharmacologic parameters at difference ages, which will allow a safe and effective administration, and its authorization by all Health Authorities.

Absorption of water-soluble vitamins

Water-soluble vitamins are required as enzyme cofactors in a wide variety of metabolic reactions. Riboflavin, niacin, and vitamin C are essential in redox reactions; thiamine and biotin are involved in macronutrient metabolism; and folate, vitamin B12, pyridoxine, and riboflavin play important roles in the regulation of S-adenosylmethionine production and DNA synthesis. Each of the water-soluble vitamins appears to require its own membrane transport process for absorption across the enterocyte. The absorption of vitamin B12, or cobalamin (Cbl), is unique in requiring multiple processes from the stomach to the ileum that involve at least four different binding proteins. Whereas all water-soluble vitamins are absorbed from the small intestine, folate, biotin, and riboflavin can be transported across colonic epithelial cells, with uncertain clinical significance. This article reviews recent studies on the requirement, metabolism, and deficiency state of each water-soluble vitamin, followed by a discussion of current knowledge on the regulation of its intestinal absorption.

Proper usage of pancreatic enzymes

With the recognition of the close link between nutritional status and pulmonary function in cystic fibrosis (CF), treatment and prevention of malnutrition have become a major focus in the modern therapeutic approach for patients with CF. Thereby, pancreatic enzyme replacement therapy plays a central role. This article reviews key publications on important aspects of pancreatic enzyme replacement therapy contained in the literature over the last 12 months. New insights into the pathogenesis of exocrine pancreatic disease, efficacy and dosing of pancreatic enzyme preparations, occurrence of fibrosing colonopathy, enzyme replacement in the context of enteral nutrition, and assessment of pancreatic function are addressed.