Should an 80-year-old patient taking Atorvastatin and Hydrochlorothiazide, and now prescribed Prednisone, take Pepcid AC (Famotidine) or a Proton Pump Inhibitor (PPI) to prevent gastrointestinal bleeding?

Gastric Protection for Elderly Patient on Prednisone with Multiple Risk Factors

A proton pump inhibitor (PPI) is recommended over Pepcid AC (famotidine) for this 80-year-old patient on prednisone, atorvastatin, and hydrochlorothiazide to prevent gastrointestinal bleeding due to multiple risk factors for GI bleeding. 1

Risk Assessment

This patient has several significant risk factors for GI bleeding:

• Advanced age (80 years old)
• Low body weight (97 pounds)
• Concurrent steroid use (prednisone 40 mg daily)
• Multiple medications (atorvastatin and hydrochlorothiazide)

According to expert consensus guidelines, these clinical characteristics significantly increase the risk of GI bleeding 1. The risk increases as the number of risk factors increases, placing this patient in a higher risk category.

Evidence for PPI Superiority

PPIs are more effective than H2 receptor antagonists (H2RAs) like famotidine for preventing upper GI bleeding:

• PPIs reduce upper GI bleeding to a greater degree than H2RAs 1
• PPIs are specifically recommended for patients with multiple risk factors for GI bleeding 1
• The 2010 ACCF/ACG/AHA Expert Consensus Document clearly states that "PPIs are appropriate in patients with multiple risk factors for GI bleeding who require antiplatelet therapy" 1

Specific Recommendations for This Patient

1. Start a PPI while the patient is taking prednisone 40 mg daily
2. Continue PPI throughout the 10-day prednisone course
3. Consider pantoprazole as it has fewer drug interactions compared to omeprazole 2
4. Take prednisone with food to further reduce gastric irritation 3

Important Considerations

• The FDA label for prednisone specifically recommends "administration of antacids between meals to help prevent peptic ulcers" when large doses are given 3
• While there are theoretical concerns about long-term PPI use, these are not relevant for the short-term (10-day) course needed during prednisone therapy 4
• The patient's advanced age (80 years) and concurrent steroid use are specifically mentioned in guidelines as risk factors requiring PPI prophylaxis 1

Potential Pitfalls to Avoid

1. Don't underestimate bleeding risk: This patient has multiple risk factors (age, steroids, multiple medications)
2. Don't use H2RA when PPI is indicated: While famotidine has fewer drug interactions, it provides less effective protection against GI bleeding in high-risk patients 1
3. Don't overlook drug interactions: If concerned about drug interactions, pantoprazole has fewer CYP2C19 interactions than omeprazole or esomeprazole 2
4. Don't continue PPI indefinitely: After completing the prednisone course, reassess the need for continued acid suppression therapy

Conclusion

Based on the patient's multiple risk factors (advanced age, steroid use, multiple medications) and the higher efficacy of PPIs compared to H2RAs in preventing GI bleeding, a PPI is the preferred agent for this 80-year-old patient during the 10-day course of prednisone therapy 1, 4.