Medical Professional Publications

Fighting “Fake News” in GI: Proton Pump Inhibitors, Gluten and PEG 3350

Columbus, OH — November 2017

Physicians hear unfounded worries from parents all the time.

MiraLAX is antifreeze.

A gluten-free diet helps in sports.

Nexium gives you dementia.

Carlo Di Lorenzo, MD, chief of Gastroenterology, Hepatology and Nutrition at Nationwide Children’s Hospital, has heard all of that as well, and knows that primary care providers have to regularly address those concerns and others like them. So during a plenary session of the 2017 American Academy of Pediatrics National Conference, he gave providers an update on some hot-button issues in the GI field, and how they can be explained to families.

“A combination of factors leads to these misunderstandings and concerns,” says Dr. Di Lorenzo, who is also a professor of Pediatrics at The Ohio State University College of Medicine. “Everyone experiences some GI symptoms, so everyone is interested in them. That means they are regularly talked about in the media. Celebrities talk about their diets. Studies can seem to be contradictory.”

Dr. Di Lorenzo focused on three topics in particular: polyethylene glycol (PEG) 3350, gluten, and proton pump inhibitors.

PEG 3350

PEG 3350, most commonly sold under the name MiraLAX, has garnered recent attention because some parents reported behavioral and other changes after children took the laxative for extended periods. Of particular concern for some parents is ethylene glycol, which is found in MiraLAX and antifreeze.

Ethylene glycol and related compounds are found in drinking water and many foods as well, says Dr. Di Lorenzo. Soon-to-be published research from Dr. Di Lorenzo and others found that children who take PEG 3350 have the same levels of those compounds as those who do not take the laxative.

That and other studies lead Dr. Di Lorenzo to say that PEG 3350 is safe and effective for many children with constipation. But so are other therapies, like Milk of Magnesia (though Milk of Magnesia is not always as palatable) and behavioral interventions, and clinicians can explore those as well.

Gluten

Approximately 1 percent of the population has celiac disease, and a tissue transglutaminase antibodies (tTG-IgA) test will frequently help diagnose it. Approximately 0.1 percent of the population has a wheat allergy, and a serum-specific IgE test can lead to diagnosis. An unknown, but likely small, percentage of the population has non-celiac gluten sensitivity, and there is no diagnostic marker for that condition.

The vast majority of people, then, do not have a medical reason for cutting gluten out of their diets, says Dr. Di Lorenzo. In fact, a gluten-free diet can lead to deficiencies in vitamins and minerals.

If patients have potentially gluten-related symptoms, physicians should test for celiac disease or wheat allergy before a patient cuts out gluten. If there is no medical indication for a gluten-free diet, providers should discourage it. There is little evidence that cutting out gluten has a benefit for athletes (a common reason for the dietary change) or any other health benefits that outweigh possible harms, says Dr. Di Lorenzo

Proton Pump Inhibitors

Proton pump Inhibitors are effective at acid suppression and should be used in treatment when there are evidence-based indications for them. They are useful for erosive esophagitis, proton pump inhibitor responsive-esophageal eosinophilia, protection from nonsteroidal anti-inflammatory drug-induced lesions and gastrointestinal bleeding.

But the inhibitors are overused, Dr. Di Lorenzo says. They do not help in many presumed cases of pediatric gastroesophageal reflux disease, for example, or functional heartburn. Parents may have a further question, however, especially in light of reports that proton pump inhibitors are associated with dementia and other conditions: should they be used at all?

Dr. Di Lorenzo says they should, but only if they are necessary. While increased risk of dementia and metabolic problems have not been demonstrated convincingly, an increased risk of enteric infection (especially with C. difficile) does seem likely, based on recent evidence.

“Before prescribing acid suppressive medication, try to make sure you are treating a condition that will benefit from it,” says Dr. Di Lorenzo. “Once a proton pump inhibitor has had the desired effect on the condition, attempt to wean the patient. The continued use of inhibitors is all right, however, if they are necessary.”

Reference:
Di Lorenzo C. “Flushing out ‘fake news’ in GI: Getting to the truth about PPIs, PEG 3350 and gluten.” American Academy of Pediatrics National Conference & Exhibition; September 16-19, 2017; Chicago.

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