High Rate of Potentially Inappropriate Prescribing of PPIs for Older People in Primary Care

This repeated cross-sectional study evaluated Irish pharmacy claims data of around 130,000 Irish older adults (≥65; 96.5% of Ireland’s older population) for proton pump inhibitor (PPI) prescriptions, every 5 years between 1997 and 2012.¹

The use of PPI increased from 10.7% in 1997 to 50.3% in 2007 and 48.4% in 2012. The odds of being prescribed a maximal PPI dose were sixfold higher in 2012 than in 1997 (aOR, 6.30; 95% CI, 5.76–6.88). Long-term prescribing became more common, with the number of those taking a PPI for longer than 8 weeks increasing from 4.1% in 1997 to 35.5% in 2012. Analysis took into consideration ulcerogenic medications (eg, NSAIDS), comorbidities, and duration of high-dose PPI use.

The Beers criteria² and the European corollary STOPP criteria, lists of medications to avoid or limit in the elderly, recommend no longer than 8 weeks of high-dose PPI for ulcers, gastritis, etc, and a reduction to low dose before stopping altogether. The same criteria also recommend against the use of NSAIDs or cox-2 inhibitors in elderly patients due to vasoconstriction contributing to cardiac and renal problems in addition to GI bleed.

I thought it was an academic medicine phenomenon that resident physicians forget to stop the PPI on discharge that was inappropriately started in the hospital for “GI prophylaxis.”³ But this study shows that, instead, the inappropriate prescribing has increased over time. Over the time of this study, polypharmacy of five or more medications also increased from 17.8% in 1997 to 60.4% in 2012, and those patients taking 10 or more regular medicines increased from 1.5% to 21.9%.⁴ Despite the increase in obesity and aging that may have contributed to higher arthritis rates and more use of NSAIDs, the incidence of PPI use without concurrent ulcerogenic medications has increased over time from 0.3% in 1997 to 4.7% in 2012. Especially noteworthy is that the number of patients at maximal PPI dose increased 30-fold from 0.8% in 1997 to 23.6% in 2012.

A somewhat surprising finding was that maximal dose use was inversely associated with the concomitant use of NSAIDs. The authors speculate that perhaps prescribing practices affected by history and comorbidities might account for some of this effect.

Hopefully, the slight decrease from 50.3% in 2007 to 48.4% in 2012 is a trend that will continue, given the risk of PPIs. PPIs place patients at higher risk of vitamin B₁₂ and magnesium deficiencies, Clostridium difficile infection, dementia,^5,6 cardiac mortality⁷ due to nitrous oxide depletion, and possibly pneumonia. (The increased rate of pneumonia has recently been put in question in a time sequence analysis.⁸)

After checking for gastritis, Barrett’s, or ulcers, I stop PPIs on hospital follow-up. In long-term users, I taper before stopping. I generally use antacids for several days to counteract the acid hypersecretion. Patients who have tried and failed antacids, I bridge with sucralfate for 1 week to 1 month, depending on the anxiety level of the patient or the doctor. University of Wisconsin Integrative Medicine Fellowship has helpful patient handouts for GERD and tapering.

References

1. Moriarty F, Bennett K, Cahir C, Fahey T. Characterizing potentially inappropriate prescribing of proton pump inhibitors in older people in primary care in Ireland from 1997 to 2012. J Am Geriatr Soc. 2016;64(12):e291-e296. http://onlinelibrary.wiley.com/wol1/doi/10.1111/jgs.14528/full
2. American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2015 updated Beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015;63(11):2227-2246. http://onlinelibrary.wiley.com/doi/10.1111/jgs.13702/full
3. Grube RR, May DB. Stress ulcer prophylaxis in hospitalized patients not in intensive care units. Am J Health Syst Pharm. 2007;64(13):1396-1400. http://www.ajhp.org/content/64/13/1396.long
4. Moriarty F, Hardy C, Bennett K, et al. Trends and interaction of polypharmacy and potentially inappropriate prescribing in primary care over 15 years in Ireland: a repeated cross-sectional study. BMJ Open. 2015;5(9):e008656. http://bmjopen.bmj.com/content/5/9/e008656
5. Gomm W, von Holt K, Thome F, et al. Association of proton pump inhibitors with risk of dementia: a pharmacoepidemiological claims data analysis. JAMA Neurol. 2016;73(4):410-416. http://jamanetwork.com/journals/jamaneurology/article-abstract/2487379
6. Haenisch B, von Holt K, Wiese B, et al. Risk of dementia in elderly patients with the use of proton pump inhibitors. Eur Arch Psychiatry Clin Neurosci. 2015;265(5):419-428. http://link.springer.com/article/10.1007%2Fs00406-014-0554-0
7. Shah NH, LePendu P, Bauer-Mehren A, et al. Proton pump inhibitor usage and the risk of myocardial infarction in the general population. PLoS One. 2015;10(6):e0124653. http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0124653
8. Othman F, Crooks CJ, Card TR. Community acquired pneumonia incidence before and after proton pump inhibitor prescription: population based study. BMJ Open. 2016;355:i5813. http://www.bmj.com/content/355/bmj.i5813