The Association between Baseline Proton Pump Inhibitors, Immune Checkpoint Inhibitors, and Chemotherapy: A Systematic Review with Network Meta-Analysis

Simple Summary Proton pump inhibitors (PPIs) are the most commonly used gastric acid suppressants in cancer patients. However, long-term use of PPIs can cause dysbiosis effects disrupting gut microbiota with subsequent impairment of the effectiveness of immune checkpoint inhibitors (ICIs). Our study demonstrates that, in advanced non-small cell lung cancer and urothelial carcinoma, patients receiving ICIs with concomitant PPIs are associated with poorer survival outcomes, when compared not only with those without PPIs but also with patients treated with chemotherapy, implying that PPIs could compromise the effectiveness of ICIs, causing them to be less effective than chemotherapy. As a result, we suggest that clinicians should avoid unnecessary PPI prescription in these patients. Conversely, there is little survival association with PPI in patients with melanoma, renal cell carcinoma, hepatocellular carcinoma, and squamous cell carcinoma of the neck and head. Nevertheless, future high quality prospective studies including more cancer types are warranted. (1) Although emerging evidence suggests that proton pump inhibitor (PPI)-induced dysbiosis negatively alters treatment response to immune checkpoint inhibitors (ICIs) in cancer patients, no study systematically investigates the association between PPIs, ICIs, and chemotherapy; (2) Cochrane Library, Embase, Medline, and PubMed were searched from inception to 20 May 2022, to identify relevant studies involving patients receiving ICIs or chemotherapy and reporting survival outcome between PPI users and non-users. Survival outcomes included overall survival (OS) and progression-free survival (PFS). Network meta-analyses were performed using random-effects models. p-scores, with a value between 0 and 1, were calculated to quantify the treatment ranking, with a higher score suggesting a higher probability of greater effectiveness. We also conducted pairwise meta-analyses of observational studies to complement our network meta-analysis; (3) We identified 62 studies involving 26,484 patients (PPI = 8834; non-PPI = 17,650), including non-small cell lung cancer (NSCLC), urothelial carcinoma (UC), melanoma, renal cell carcinoma (RCC), hepatocellular carcinoma (HCC), and squamous cell carcinoma (SCC) of the neck and head. Eight post-hoc analyses from 18 randomized-controlled trials were included in our network, which demonstrated that, in advanced NSCLC and UC, patients under ICI treatment with concomitant PPI (p-score: 0.2016) are associated with both poorer OS (HR, 1.49; 95% CI, 1.37 to 1.67) and poorer PFS (HR, 1.41; 95% CI, 1.25 to 1.61) than those without PPIs (p-score: 1.000). Patients under ICI treatment with concomitant PPI also had poorer OS (HR, 1.18; 95% CI, 1.07 to 1.31) and poorer PFS (HR, 1.30; 95% CI, 1.14 to 1.48) in comparison with those receiving chemotherapy (p-score: 0.6664), implying that PPIs may compromise ICI's effectiveness, making it less effective than chemotherapy. Our pairwise meta-analyses also supported this association. Conversely, PPI has little effect on patients with advanced melanoma, RCC, HCC, and SCC of the neck and head who were treated with ICIs; (4) PPI-induced dysbiosis serves as a significant modifier of treatment response in both advanced NSCLC and UC that are treated with ICIs, compromising the effectiveness of ICIs to be less than that of chemotherapy. Thus, clinicians should avoid unnecessary PPI prescription in these patients. PPI-induced dysbiosis, on the other hand, does not alter the treatment response to ICIs in advanced melanoma, RCC, HCC, and SCC of the head and neck.

Automated summary

Proton pump inhibitors (PPIs) can disrupt gut microbiota and compromise the effectiveness of immune checkpoint inhibitors (ICIs) in cancer patients. Our study shows that patients with advanced non-small cell lung cancer and urothelial carcinoma who receive ICIs and concomitant PPIs have poorer survival outcomes compared to those without PPIs or receiving chemotherapy. However, PPIs have little impact on survival outcomes in patients with melanoma, renal cell carcinoma, hepatocellular carcinoma, and squamous cell carcinoma of the neck and head.