Should I increase pantoprazole to BID or change to a different PPI for a 91 YOF with recalcitrant GERD?

From the Guidelines

For a 91-year-old female with recalcitrant GERD, increasing pantoprazole to twice daily (BID) is a reasonable first approach before switching to a different PPI. This approach is supported by the most recent and highest quality study, which suggests that a 4- to 8-week trial of single-dose PPI therapy can be escalated to twice-a-day dosing or switching to a more potent acid suppressive agent if symptoms persist 1. Consider increasing from the standard 40mg once daily to 40mg twice daily, taken 30 minutes before breakfast and dinner. This approach maximizes acid suppression throughout the day and night, which is particularly important for elderly patients who often have more severe symptoms and complications from GERD.

Some key points to consider when managing GERD in elderly patients include:

• Non-pharmacological approaches like elevating the head of the bed, avoiding meals within 3 hours of bedtime, and eliminating trigger foods can be beneficial 1
• Potential drug interactions with clopidogrel, warfarin, or certain antifungals should be monitored 1
• Long-term PPI complications such as vitamin B12 deficiency, hypomagnesemia, and increased fracture risk should be considered, particularly in this age group 1
• If increasing pantoprazole to BID does not provide adequate relief after 2-4 weeks, switching to a different PPI such as esomeprazole 40mg daily or rabeprazole 20mg daily may be beneficial, as individual response to different PPIs varies 1

It is essential to weigh the benefits and risks of PPI therapy and to involve the patient in a shared decision-making model, as recommended by the AGA clinical practice update on the personalized approach to the evaluation and management of GERD 1.

From the FDA Drug Label

In a series of dose-response studies, pantoprazole, at oral doses ranging from 20 to 120 mg, caused dose-related increases in median basal gastric pH and in the percent of time gastric pH was > 3 and > 4. Treatment with 40 mg of pantoprazole produced significantly greater increases in gastric pH than the 20 mg dose Doses higher than 40 mg (60,80,120 mg) did not result in further significant increases in median gastric pH.

The patient is already on pantoprazole 40mg/day, and increasing the dose to BID (twice daily) may not provide additional benefit in terms of gastric acid suppression, as doses higher than 40 mg did not result in further significant increases in median gastric pH. Changing to a different PPI may be considered, but there is no direct evidence in the provided drug labels to support the efficacy of one PPI over another in this specific scenario. 2 2 2

• Key points:
  • Doses higher than 40 mg did not result in further significant increases in median gastric pH
  • Changing to a different PPI may be considered, but there is no direct evidence to support the efficacy of one PPI over another in this scenario
  • The decision to increase the dose or change the PPI should be made on a case-by-case basis, taking into account the individual patient's response to treatment and medical history.

From the Research

Treatment Options for Recalcitrant GERD

• Increasing the dose of pantoprazole to twice daily (BID) may be considered for a 91-year-old female (YOF) with recalcitrant gastroesophageal reflux disease (GERD) despite being on pantoprazole 40mg/day, as dose escalation has been shown to improve acid control in patients with symptoms of GERD 3.
• Alternatively, changing to a different proton pump inhibitor (PPI) may be an option, as some PPIs have been shown to provide greater acid control than others, with esomeprazole providing significantly greater acid control than pantoprazole on a milligram-per-milligram basis 3.
• The optimal adult oral dose for gastric acid-related disorders is pantoprazole 40 mg once daily, but individualized treatment may be necessary for patients who do not respond to standard doses 4.
• Maintenance therapy with a PPI is often necessary for patients with GERD, and the dose should be individualized using a titration technique, such as the "New Step-down therapy" approach 5.

Considerations for the Elderly Population

• GERD appears to be more common and more severe in the elderly, and pantoprazole has been shown to be an effective treatment for this at-risk population 6.
• The selection of a PPI for an elderly patient should be based on the individual patient's needs and medical history, as well as the potential for drug interactions and side effects 4, 6.
• The efficacy and safety of PPIs, including pantoprazole, have been demonstrated in short- and long-term studies, and they are generally well tolerated in adults with acid-related disorders 4, 6.