Narrator - Dr. Abel  00:00
Welcome to HelixTalk, an educational podcast for healthcare students and providers, covering real life clinical pearls, professional pharmacy topics and drug therapy discussions. This podcast

Narrator - ?  00:11
is provided by pharmacists and faculty members at Rosalind Franklin University, College of Pharmacy.

Narrator - Dr. Abel  00:17
This podcast contains general information for educational purposes only. This is not professional advice, and should not be used in lieu of obtaining advice from a qualified health care provider.

Narrator - ?  00:27
And now on to the show.

Dr. Sean Kane  00:31
Welcome to HelixTalk episode 57 I'm your co host, Dr

Unknown Speaker  00:34
Kane. I'm Dr. Schuman, and I'm Dr. Patel,

Speaker 1  00:37
and so today, again, I'm going to kind of take the lead a little bit differently this time. And we're bringing up the topic of PPIs, or, as we like to say, kicking acid, taking names, the story of PPI use, or proton pump inhibitors

Dr. Sean Kane  00:48
heavy use, and perhaps not even PPI use, but PPI abuse, right? Yeah, exactly.

Speaker 1  00:52
And that's going to be something to really look at. Is this is one. I think it's been coming up in the news from time to time over the last few years, and different FDA warnings come about a little there's a lot of information and concern about these medications.

Dr. Sean Kane  01:04
Let's jump into some of the pharmacology of the PPIs. Just to give a good background on what these medications are doing. That kind of informs other topics that we'll be talking about, hopefully. As the listeners know, these are hydrogen potassium ATPase exchanger inhibitors, so they're blocking the stomach's ability to secrete hydrogen ions into the stomach in the form of stomach acid.

Speaker 2  01:25
And it's actually available to treat a lot of different gi conditions, mainly GERD, erosive esophagitis, you know, gastritis, ulcers, some of those secretory conditions, such as Zollinger Ellison syndrome, in which the GI cells, GI tract produces more acid than needed, and it's also part of the combination regimen to treat the h pylori infection.

Speaker 1  01:49
And these are ones that I would love to hear Dr. Kane's comments. But if you seem to get a lot of use in individuals getting admitted to the hospital, is a lot of part of your GI prophylaxis.

Dr. Sean Kane  01:58
Where this comes from is that with critical illness in certain patient populations, we do see what's called stress ulcer related GI bleeding. So patients because of the stress that they have, whether it's because they're septic on vasopressors or a host of other things going on, they're at risk for having clinically relevant GI bleeding because of their critical illness. The problem, though, is, as we'll talk about, this has been extrapolated from a very small group of patients who truly are indicated for stress Ulcerative prophylaxis to a wide variety of even non ICU patients, just because they're in the hospital, commonly, they'll get stress Ulcerative prophylaxis, and that's really an inappropriate thing to do,

Speaker 2  02:37
yeah, and I guess the common stream is that sometimes the transitions of care comes in very handy when patient go from very stressful ICU type condition to general medicine floor and then to community. And some of these PPIs are then continued, even through those transitions, and kind of gets woven into patients outpatient regimen where they don't really have any clinical indication.

Speaker 1  02:59
And I believe that's a great transition there. Dr. Patel is looking at, so even outside of the hospital setting, what about, what about outside of there? And so I think the one way to look at it is, in recent years, a number of these agents have come out in over the counter forms, and really they're in these kind of 14 day courses a lot of times. And to me, I see that as one of those kind of wink wink, nudge nudge moments that we sell in 14 day courses. Because really, we want you to limit it to that, but we know you're probably going to be on it a while. It's kind of like how they talk about, you know, using these sleep aids for short periods of time. But again, that's a rant for a different day. What we do know, though, is OTC sales from all antacids, whether it's H2RAs, PPIs, et cetera, was $2.6 billion in 2015 so PPIs are a big piece of that is a

Dr. Sean Kane  03:41
lot of use. And even if we transition to the prescription market, we're seeing $13.6 billion in 2009 which, you know, is older data at this point. And that does make PPIs one of the top therapeutic classes in the United States in terms of volume, and fifth in terms of volume in the world. So we're seeing a lot of this usage of these PPIs,

Speaker 2  04:02
you know. And I was really surprised when they initially rolled out, you know, I remember reading during college of pharmacy education time too, where most of the side effects was, you know, negligible type of side effects, no big deal, no big warnings and stuff. And as the time has evolved, we're learning more and more about some of the grave issues that a PPI long term use can cause.

Speaker 1  04:24
Yeah, right before we get to some of those specific ones, is a little bit of data, just going to what you both have mentioned about the kind of these medications sometimes being used indefinitely. There was a study of an ambulatory care practice in New York City, and they found that about 30% of their geriatric patients on PPIs really lacked any clear indication for use, and that's something that was even replicated in another study that for again, from where we're at, this was a specific in a Midwestern population, those patients in nursing facilities in Iowa and Illinois, they found is 80% of patients received a proton pump inhibitor. Total drug costs of $350,000 and. Of those, 65% had no diagnosis listed as justifying use.

Speaker 2  05:05
And so I've not done any studies Dr. Schuman, but if I were to do one study for the patient I encounter in my clinic for medication reconciliation, I see that PPIs are prescribed left and right without any indication, or left alone at very high doses, so there is no de escalation of dose or de escalation of therapy considered at all, and these patients are left on PPIs.

Dr. Sean Kane  05:28
And really the reason that we're seeing that, you know, there's many factors. Some of the big factors are a they're extremely effective for heartburn symptoms, so patients associate them very strongly with having a good efficacy to healthcare providers and patients don't associate them with side effects, even though they do have side effects that we'll talk about most commonly, patients and providers don't view them as something that has a negative side to them. Then, three, especially with the transition of care, it's very easy to add medications to a patient's profile. It's very difficult for a provider to start taking things away because they're worried about stepping on other providers feet. They don't know why it was started in the first place. So the idea of a drug act to me, is very, very difficult, whereas adding new stuff is very easy to

Speaker 2  06:13
do, yeah, and I mean, think about it, if I'm taking PPIs, you know, those 14 day courses you talked about over the counter, and I find those expensive, but then my insurance covers it. So I go to my doctor and say, Hey, can you turn this into a prescription, which will be covered through my insurance. I'm not paying as much for the over the counter. This physician is probably not going to do any tests, any form of diagnosis. They're just going to give a prescription. And this just saga continues and becomes a part of the prescription record. You just talked about Dr. Kane, right?

Speaker 1  06:42
We get so specific about certain medication classes, whether it's for pain or for anxiety, but that this is one that, for the most part, gets, gets a bit of a pass. And for me, the first times that I really started to start to hear about it, more was with the Beers criteria. For some of our listeners, may know the Beers criteria is a way of looking at certain medication classes that are problematic in geriatric patients. And there's a lot of these, lot of anti cholinergic medications end up on here, a lot of anti histamines. And in 2015 they actually went ahead and added PPIs on there on their list of potentially inappropriate medications. And that was first time that one popped up on the list. And it really, I think, has started to lead to is a little bit more related literature coming out about Okay, now let's, let's give a a real, closer examination into what, what are some concerns with these?

Dr. Sean Kane  07:25
There's a lot of more long term, chronic side effects that are now being associated with ppi use. I think it's one thing that we have to emphasize is that almost all of these side effects are not acute use of PPIs. These are chronic, long term use. And again, even with the OTC labeling, they have this 14 day course. You have to wait four months between 14 day courses. Again, we commonly that's not happening, and commonly, patients are just on it lifelong. So very often we are seeing PPIs being continued indefinitely, and that's where we're seeing some of these more chronic side effects that we're seeing.

Speaker 2  07:59
So the very first time FDA kind of put out this type of watch or warning due to the chronic use of ppi, was in 2011 and they indicated that the PPIs can decrease the magnesium levels. And it was so profound that 25% of the patient supplementation with magnesium didn't even correct that low magnesium issue, and it led to the discontinuation of ppi, which kind of reversed the situation of the magnesium levels being low.

Speaker 1  08:29
And some of the literature that's even come out discussing that is what's one of the things when I do my lectures on fluids and electrolytes, we talk about the idea that tissue levels of magnesium, you can't always predict tissue stores based upon a serum level. So for number of individuals, they could be even higher amounts. You know that based on the level, an individual may be fine, but that really they have, like a subclinical hypomagnesemia. So these these percentages may be even higher,

Dr. Sean Kane  08:54
really, the next chronic adverse effect that we worry about is actually osteoporosis. This came out primarily from a retrospective article looking at patients greater than 50 years of age or older who were on high doses of PPI therapy for greater than one year, they found that they were at a slightly higher increased risk of fracture. The FDA actually did modify their labeling to acknowledge this potential risk, although more recent data has now become a little bit mixed whether this truly is a medication that can increase your fracture risk or not, in terms of mechanisms, it's not super clear. We do know that certain types of calcium do require acidic environments in order to be absorbed. So potentially, if patients on PPIs that have high gastric pH don't absorb that calcium, potentially that could predispose them to osteoporosis, therefore increased risk of fracture. But then we have other studies that kind of refute that as well. So definitely one of the gray areas, but certainly it's not promising. Signal that we've seen in the literature regarding fracture

Speaker 1  09:57
risk, and again, the Beers criteria specifically. Philly mentioned that this was one of the driving forces for them, leading to that learning in the elderly, was this concern about osteoporosis and risk of fractures, right?

Speaker 2  10:08
And I do actually treat quite a bit of osteoporosis in the clinic that I serve, and I love to quiz my students on the mechanism of why, or theoretical mechanism of why, PPIs can lower the calcium levels. And magically, or surprisingly, I should say that the physicians, even after bringing up the issue that, hey, this patient has unjustified use of PPIs, chronic use of PPIs, maybe we should investigate with whether this was the reason for their developing osteoporosis, and they still leave them on these PPI agents. So what I've tried to do is try to educate the patient. And most of the patients are hearing all these things coming up in the news too, and they're actually listening to what we have to say and maybe agreeing to even these de escalation of PPI therapy.

Speaker 1  10:56
Right? That's why it's important to really look at kind of the truth or the, you know, the which roads are the biggest concerns. I think another one to look at now is decreased B 12 levels. And this is one that I think is a little bit more recently, but they found the use of PPI is greater than three years seems to impair absorption of vitamin B 12. And this is one thing that we already know, that B 12 levels, it depends upon in something called intrinsic factor within the gut to help with absorption. It's the reason why a number of elderly individuals may be deficient in B 12, and something that's a B 12 being involved in neurologic functioning a lot of times. If we can't do it orally because of absorption, we'll do B 12 injections to get around that stomach absorption. So we already know there's an issue with B 12 with age. And so we add on the fact that an individual may be on a ppi, and now maybe that's a double whammy in terms of impairing their B 12 absorption. So again, the reason why this matters is that we know that B 12 has a role in nerve signaling, red blood cell development, so think potentially megaloblastic or macrocytic anemia, paresthesias, impaired cognition, again, issues that are already of concern on the elderly. So once again, we're just, are we potentially adding to these, these concerns, and again, fall risk if we're thinking about impaired cognition. So one thing to note, though, is there's also this, this potential concern about about dementia, and that one again, may be due to B 12, maybe due to a whole host of other factors. That one in particular, though, the evidence is less solid. What we have there, it's concerning, obviously, but the hazard ratio in one study was 1.16 and so again, a significant, you know, a statistically significant, but as far as clinically significant, that's something that remains to be seen.

Dr. Sean Kane  12:34
Then, for the listeners, a hazard ratio 1.16 means that you're 16% or 1.16 times as likely to develop dementia as someone not on a ppi. Another less chronic side effect that is associated with ppi use is actually pneumonia and C diff, diarrhea, and most of this data actually comes from the inpatient side as opposed to the outpatient side. Again, in thinking about the mechanism, the proposed mechanism is that if you're on a ppi and your stomach acid isn't what it should be, and your pH is too high that potentially could allow colonization of your GI tract that would normally be sterile. And if you aspirate any of your GI contents, then you would be at risk for pneumonia. And also, if you were to ingest certain bacteria, such as Clostridium difficile or C diff, normally, if you had enough stomach acid to kind of kill that bacteria. Now you don't — potentially that could increase your risk of C. difficile or pneumonia. There were a couple of meta analysis that either showed an increased risk of hospital acquired pneumonia or community acquire pneumonia among PPI users, and then with C diff. We do see a signal again, of PPI use being associated with C diff. But we also see other relevant factors, most specifically age and also use of broad spectrum antibiotics, which are very well known risk factors for C Diff as well.

Speaker 1  13:51
And again, this was another factor that within the Beers criteria, they said this, this, along with osteoporosis, was a reason why that this was added to the list of potentially inappropriate meds.

Speaker 2  14:00
And as you mentioned earlier, Dr. Schuman with the B 12 deficiency causing some of the megaloblastic and macrocytic anemia. There is some theories that you know the iron absorption can also be affected. One of the studies showed 52% decrease in iron among those receiving PPI, compared to 28% receiving cimetidine, and there are some case reports in small studies, but again the evidence is mixed, so we don't know if it's really coming from low iron or low B 12 levels, but anemia could be seen in a patient using long term ppi. Yeah, so

Speaker 1  14:34
this is one I think we'll continue to learn more about over time, probably not as a slam dunk as far as the direct correlation, but is going to be one to look for now, Dr. Kane, the one I really you know when looking at this one I really want to discuss with you is this idea about looking at interactions regarding the CYP enzyme system. So I know you do a lot of work discussing with students about medications like clopidogrel or Plavix, and of course, I learned in pharmacy school, as well as our lectures, we talk about that interaction with the enzyme system. And so we know that omeprazole, in particular, one of the PPIs, does have some some drug interactions. What is what does that mean

Dr. Sean Kane  15:10
for your patient population? Yeah, you know, a lot of this data came out of actually, a va retrospective analysis, where they compared patients that got a ppi and were given Plavix or clopidogrel, versus patients that did not get a PPI that were given Plavix or clopidogrel, and what they found was the PPI group were sicker. And really in all of these studies, these are all retrospective studies where they're trying to compare PPI users versus non PPI users. The problem is that the PPI user group is always sicker. They have more healthcare exposure, they have more medications, they have more comorbidities. So then you have to statistically adjust for that. And the problem in that statistical adjustment is that you can't be 100% sure that you've adjusted for all of the relevant factors mathematically.

Speaker 1  15:54
Yeah, and Dr. Kane, that's when I was thinking about, like, the one I was thinking in my head is, for example, we know that things like caffeine and nicotine can affect the lower esophageal sphincter, increase their risk of GERD. So you have an individual who's a smoker, and as a result of being a smoker, they may have more GERD, and so they end up on a ppi. Are you attributing it to the PPI use or the smoking which led to the use of the PPI Exactly?

Dr. Sean Kane  16:15
And there's actually a term for this called residual confounding, which means that you've tried to adjust for all these confounders, like smoking, but maybe there's some residual or leftover confounders that you don't know about or that you haven't adjusted for appropriately. So in terms of the omeprazole Plavix interaction, at least with this, we do have good biochemical data showing that we do truly have an interaction where the activation of clopidogrel is impaired with co‑administration of omeprazole, we know that for sure. What we don't know for sure is whether that interaction is clinically relevant enough outside of a test tube environment that you could potentially be at a higher risk for strokes and heart attacks and things like that. So I think that as a community, the most appropriate thing is a, do they really need the PPI B if they do need a ppi, we do have biochemical data saying that other PPIs probably don't cause that interaction, like pantoprazole, for example. You know the data is mixed in terms of whether you can administer your PPI separately in terms of timing from your clopidogrel, and still have this drug interaction or not. From my point of view, if I was a patient, I probably would avoid omeprazole, simply because why take the risk? So take pantoprazole. Probably better to take an H2RA, but given that we have some data that says that there may be this impact, I think it's very reasonable to pick something different.

Speaker 2  17:36
Yeah, and I think FDA, after learning this, they also put out a statement that if you must have a patient on a PPI and they're taking clopidogrel, the preferred agent would be pantoprazole.

Speaker 1  17:47
And there's even one thing just to go swing into my psychiatric world. There's even some concern that its 2C19 inhibition could potentially impact certain antidepressants, I think of citalopram and some of our tricyclics, like amitriptyline and nortriptyline, which are metabolized that way, you could theoretically, again, have an issue with increased levels of those drugs. So that'd be something to to keep, keep awareness of. So I think the big thing here is to talk, and we kind of alluded to this a little bit, is what's really the verdict, the 2015, again, the Beers criteria, what they state as a conclusion, is for elderly individuals really, to avoid scheduled use for greater than eight weeks.

Dr. Sean Kane  18:25
And you know, if you think about it, there's a lot of different reasons for that. It's not simply because of healthcare cost or these chronic side effects or pill burden, it's all of these things. So to me, a patient really has to demonstrate a need for chronic therapy that they have to know why they're on it. The prescriber has to know why they're refilling that prescription. Things like that, which should be true for any medication is just unique to ppi, is that we associate it with such good efficacy and such a benign safety profile. We probably shouldn't given some of the data that we've seen with them.

Speaker 2  18:57
Yeah, I like to emphasize what you just said, Dr. Kane, and focus on the reassessment, or the assessment of the therapy, because it's very easy for a patient to just want a medication to fix the problem without doing some of the lifestyle modifications that are, that are there. And, you know, it's just for prescriber. It could be as easy as, you know, writing a pill and they'll take care of an issue, rather than me sitting here going over and asking you some of the triggers that can cause the heartburn, what's bothering you, and not really assessing that, and then patient comes back to you, they still continue those activities that are triggers, don't modify them, and they come back in a month or two and say, well, that 20 milligram dose didn't really do anything. So the next trigger that the prescriber would have to just up the dose to the next possible dose, which would be the highest dose, and then the patients left off. And I think the patients do think that by taking this medication, they can go out and eat whatever they want. And I think a patient education, as well as provider education, would be very pertinent to. Curtail the use of long term PPIs,

Speaker 1  20:02
yeah, again, is it to be fair? This is not just p guys. This is the same conversation we have a lot of disease states about when we evolve things like total diet and lifestyle modifications or sleep hygiene, that we run to. This issue about a pill that gives me the freedom to do things that maybe, versus just restricting some of those behaviors or some of those foods would also be efficacious. But hey, if the med doesn't have problems, you can keep doing that. And this is where we emphasize that perhaps there are some concerns to where it may be better to focus on non pharmacologic methods.

Dr. Sean Kane  20:29
And I don't want to give the audience the impression that we're PPI haters. You know, there are certainly indications where chronic, long term use of PPIs is more than reasonable, at least in my world, those patients that come in with a clinically relevant GI bleed secondary to a gastric or a duodenal ulcer, they probably should be on a PPI for a pretty long time, especially if it was a hemodynamically unstable bleed. We don't want that to happen again, and I'm more than willing to take the risk of C diff, fractures, pneumonia, B 12 deficiency, iron deficiency, given that it's kind of unclear what the actual risk for those is, I would rather have those risks over a patient having another bleed that could potentially kill them. That's a really big deal.

Speaker 1  21:10
Certainly, there's a couple of papers more recently that have said that exact same thing. And to be fair, part of it too is because if we do consider another class of meds, even the Beers criteria will still say, well, H2 blockers may have some they have some concerns there about CNS changes. So they're not a slam dunk. And even if we look at a Cochrane Review they did, just did a recent one, I believe, in 2015 that found that PPIs are more effective than H2 blockers. So again, is there are many good reasons and they work, and that's one of them. But just to be careful,

Speaker 2  21:38
yeah, and some of the valid diagnosis that could have PPI as a long term use would be one of them you mentioned, you know ulcers causing, you know, hemodynamic instabilities with excessive bleeding. And next one could be chronic use of NSAIDs in cases of patients who have rheumatoid conditions, chronic use of corticosteroids, or those older patients who are receiving double or triple anticoagulation, which are those patients are, but the age being one of the risk factor at higher risk of bleeding, so protecting what the PPI is a long term PPI use is valid in them.

Dr. Sean Kane  22:17
I think you know, as as healthcare providers, we absolutely need to remember some of these indications that have a justified chronic use to them, but also recognizing that that's a vast minority of the patients on PPIs. The vast majority of PPI use is I had heartburn this one time, and I got put on PPIs, and it worked great. So now I don't want to stop it. And that's the problem where those patients probably should have a trial of weaning down their dose. They probably should have a trial of maybe even switching to an H2RA, because we do see rebound heartburn when we discontinue some of these agents. So it's very reasonable to cut it down. See how you do. Cut it down farther, see how you do, maybe switch to another agent temporarily. That's a very reasonable thing, depending on how long you've been on it, as long as we recognize that most patients probably shouldn't be on it and are still on it.

Speaker 2  23:04
Yeah, and I think going back to my pharmacy school days and being p4 student, you know, working in an internal medicine team rounding when we would bring up the doses of PPIs and proper de escalations or the transition of care kind of recommendations, that was probably the last battle that we wanted to fight with the physicians out of all the recommendations we wanted to put through, right so that didn't really got through. And I think I'm feeling the same thing when I have that recommendation for the clinicians today in my clinic itself, it's probably the last fight that I want to fight, but because I do have that collaborative agreement where patients are referred to me for medical therapy management, and I can make some of the changes. I do suggest alterations such as, you know, changing them to H2RAs, or try de escalating the dose, and try to educate them on some of the lifestyle modifications, sit down and talk to them about it. That helps.

Dr. Sean Kane  24:00
Dr. Patel, as you mentioned, like the patient may be the best advocate in the scenario in your clinical environment where you can talk to them and say, Do you think it's time to try taking this away? And if the patient is the advocate to start de escalating their own drug therapy regimen, then that's a very easy win for you to convince a physician or prescriber to start backing off. It's what the patient really

Speaker 1  24:21
wants to and just to expand upon what Dr. Patel said again, some of those lifestyle modifications, again, to reiterate, things like decreasing smoking, exercising, losing weight, moderation regarding alcohol and intake, a lot of these things as well, can decrease the pill burden. Again, you have to get the patient to be an advocate for themselves so they're motivated to do those things. And then that change within the patient can then drive the provider to maybe bring back off the med.

Dr. Sean Kane  24:45
You know, if you think about it, I've never met a patient that wanted to be on more medicines, that wanted to have more co pays, that wanted to have a bigger pill burden. So, you know, focusing on those things, I think, is a very reasonable approach in thinking about. Is it time to start de escalating? You know, a patient's PPI use?

Speaker 2  25:03
Yeah, I do, do get those patients with medication reconciliation. Well, I just think I'm on too many medications, and I want to get rid of them. Well, this probably is a low hanging fruit. And sometimes I ask them, you know, why are you on this medication? That's my first question. And they have no idea. I asked them if they had any ulcers? Were they in the hospital? They were they told that they got erosive esophagitis? No, they don't remember any of them. So the patients are not even referred to appropriate gi doctors to do further investigation as to why they're getting more acid production. They're just placed on chronic PPIs. So again, maybe one of the resources could be referring them to gi services and finding out further issues.

Speaker 1  25:45
All right, so just to go ahead and summarize some of the things we've talked about, is that a few of them, the main drivers, in terms of where the warnings of concerns have come from, from, like the Beers list or the FDA, has been in particular about things like osteoporosis or in risk of falls and fractures, infections, whether it's pneumonia or C Diff associated diarrhea, and then the third one being a magnesium deficiencies, although, again, to be honest, we're still trying to look at whether this is a correlation or causation, because we do have, as Dr. Kane mentioned, a lot of These confounders, some of those, those lifestyle behaviors, whether it's smoking, and these things that we try to tease out of the data, but that may still be living a residual confounder,

Speaker 2  26:28
yeah, and let's be honest, when you have heartburn, life is not good, but at the same time, if your choices that you're making in your daily life is the reason for heartburn, education for patients to do so, some of those lifestyle modifications, such as losing some weight, relieving that pressure on the sphincter, you know, decreasing alcohol intake, smoking, exercise and those trigger foods that are so yum, but you kind of have to modify, or modify the intake itself. That can help too, and then considering some of the other type of medications that to relieve excessive acid production, suggests the H2RA blocker could be an option as well.

Dr. Sean Kane  27:09
You know, one of the problems, as we discussed, is that providers are viewing these as highly efficacious, extremely safe medications. For that reason, de escalation, especially if it's from, let's say the pharmacist said as a recommendation. It's not viewed as a sexy recommendation to have happened. So there's a lot of resistance to kind of de escalating a patient's therapy when a physician or another prescriber doesn't know why they're on it. So really, from my point of view, I think the the optimal time to think about, you know, getting rid of these PPIs is at the source. So prevention is probably the best way. And typically that's the transition of care where it was added because they're in the hospital or in the ICU for stress, also prophylaxis, that's the best time to think about, do they really need to be on this ppi? And honestly, if the patient doesn't know why they're on it, and they haven't had some of these compelling reasons for chronic PPI therapy, it's probably okay to talk to them about getting rid of it, as opposed to just continuing it, because it's what they've always been on. So with that, that wraps up episode 57 kicking acid, taking names, the story of PPI use and abuse. For those listeners who enjoyed the show, please give us a five star review on iTunes. We're also available on Twitter, at HelixTalk and at HelixTalk.com with that, I'm Dr. Kane, I'm Dr

Speaker 2  28:23
Schuman, and I'm Dr. Patel, and as usual, study hard.

Narrator - Dr. Abel  28:27
If you enjoyed the show, please help us climb the iTunes rankings for medical podcasts by giving us a five star review in the iTunes Store. Search for HelixTalk and place your review there to

Narrator - ?  28:39
suggest an episode or contact us. We're online at HelixTalk.com thank you for listening to this episode of HelixTalk. This is an educational production copyright Rosalind Franklin University of Medicine and Science.