Long-Term PPIs May Be Overused in Nursing Homes

      Results from a large multicenter, cross-sectional study suggest that nearly half of nursing home residents receiving proton pump inhibitors (PPIs) were prescribed the drugs for “non-evidence-based indications.”
      PPIs are indicated for gastroesophageal reflux disease (GERD), erosive esophagitis, duodenal ulcers, risk reduction for gastric ulcer, and other gastric disorders. PPI use in the elderly has increased over the last decade, and as many as 20% of residents 80 years or older have been prescribed PPIs.
      The American College of Gastroenterology recommends an 8-week course of PPIs to treat GERD, and long-term use has been associated with an increased risk for community-acquired pneumonia, Clostridium difficile infection (CDI), and fractures. The proportion of residents taking extended courses of PPIs has risen with increasing age: about 40% of adults 80 and older continue to use PPIs 2 years after their first prescription.
      “Almost 49% of the use is not evidence-based,” said Rajender R. Aparasu, PhD, professor and chair of the Department of Pharmaceutical Health Outcomes and Policy at the University of Houston College of Pharmacy. “There is a critical need to minimize the exigent use of PPIs. Most PPIs are indicated for short-term use, [but] patients are using these medications for very long periods of time. We need to look at how long a patient has been on a PPI and whether they still need to be on a PPI.”
      Dr. Aparasu and colleagues reviewed data on 1.31 million elderly nursing home residents collected in the 2004 National Nursing Home Survey and found that a total of 355,600 residents (26.7%) received at least one PPI. Of those, 48.6% received PPIs for a non-indicated condition (Res Social Adm Pharm 2017;13:358–363).
      Patients with Medicare were more likely to receive an inappropriate prescription for PPIs compared with residents with some other form of insurance. The researchers also found that nursing home residents in micropolitan areas (populations ranging from 10,000 to 50,000) were less likely to receive an inappropriate PPI compared with those in metropolitan areas.
      Most of the elderly nursing home residents receiving PPIs were women (74%), older than 85 (48%), non-Hispanic (96%), and white (88%). Most were residents in for-profit nursing homes with a capacity of 100 to 199 beds, 76% of which are located in metropolitan areas.
      “There is an urgent need to optimize PPI use in the elderly.”
      Dr. Aparasu said residents are given PPIs for longer than the recommended period for several reasons. A physician may be reluctant to overrule a colleague’s treatment order or may not want to risk changing medications in a stable patient. He said physicians need to make a decision in the patient’s best interest: “It’s very important that — in patients who are on existing PPIs, when [the drug is] no longer needed — they have to be stopped.”
      Dr. Aparasu and his team have completed a study evaluating safety outcomes, particularly pneumonia and fractures, for patients on long-term PPIs which he expects to be published soon.
      The results from another study conducted at the 103-bed Park Place Nursing and Rehabilitation Center in Selma, AL, illustrate the dangers associated with long-term PPIs.
      Amareswari Gottipati, MD, and colleagues at University of Alabama-Birmingham Selma Family Medicine evaluated long-term residents of Park Place who were 65 and older (J Am Med Dir Assoc 2017;3:B22). A total of 43 residents were receiving at least one PPI. Of these residents, the researchers found only six had been diagnosed with gastric ulcer, bleeding, or gastritis, and none needed PPIs.
      After the residents’ PPIs were discontinued, they were observed prospectively for 1 year. The researchers noted an increased risk of fractures of the hip, shoulder, and wrist in six patients (13%). Two residents developed diarrhea due to CDI. Three residents were restarted on PPIs due to increased gastritis and gastric ulcer with bleeding.
      “Given the safety concerns and high prevalence of PPI use in nursing home residents, there is an urgent need to optimize PPI use in the elderly,” Dr. Gottipati concluded.
      Braxton Poe is a freelance medical writer based in the Philadelphia area.