Is it appropriate to use a proton pump inhibitor (PPI) for gastric protection in an 84-year-old patient on chronic nonsteroidal anti-inflammatory drugs (NSAIDs)?

PPI Use for Gastric Protection in an 84-Year-Old Patient on Chronic NSAIDs

Yes, it is appropriate and recommended to use a proton pump inhibitor (PPI) for gastric protection in an 84-year-old patient on chronic NSAIDs due to their high risk of gastrointestinal complications. 1, 2

Risk Assessment for NSAID-Related Gastrointestinal Complications

The 84-year-old patient has multiple significant risk factors for NSAID-induced gastrointestinal complications:

• Advanced age (≥65 years): Increases risk approximately 2-3.5 fold 1
• Chronic NSAID use: Increases risk of serious gastrointestinal complications by 2.5-5 fold compared to non-users 1

These risk factors place this patient in a high-risk category for developing NSAID-related gastrointestinal complications, including peptic ulcers and bleeding.

Evidence-Based Recommendations

According to the Alimentary Pharmacology and Therapeutics guidelines, for patients aged ≥65 years:

• Using an NSAID alone is rated as "uncertain" or "inappropriate" depending on other risk factors 1
• Using an NSAID + PPI is rated as "appropriate" 1

Table 6 from the guidelines specifically addresses patients aged ≥65 years and clearly indicates that NSAID + PPI is an appropriate treatment strategy 1.

Specific Recommendations for This Patient

For this 84-year-old patient on chronic NSAIDs:

1. Add a PPI for gastroprotection - This is strongly recommended based on age alone 1, 2
2. Continue PPI for the entire duration of NSAID therapy - As recommended by the American College of Gastroenterology 2
3. Consider regular monitoring of GI symptoms, renal function, and blood pressure 2

Additional Considerations

• H. pylori testing: Consider testing and treating H. pylori if the patient has a history of ulcer or ulcer complications 2
• NSAID selection: If possible, use the NSAID with the lowest effective dose and shortest duration necessary 2
• Alternative approaches: If the patient has very high risk (multiple risk factors or previous GI bleeding), consider a COX-2 inhibitor + PPI instead of a nonselective NSAID + PPI 1, 2

Potential Concerns with Long-term PPI Use

While PPIs are generally well-tolerated, long-term use may be associated with:

• Potential for hypomagnesemia
• Risk of bone loss and fractures
• Increased risk of Clostridium difficile infection
• Medication burden and cost
• Potential drug interactions 2, 3

However, these risks are outweighed by the significant reduction in NSAID-induced gastrointestinal complications in this high-risk patient 4.

Conclusion

Based on the most recent and highest quality evidence, an 84-year-old patient on chronic NSAIDs should receive gastroprotection with a PPI due to their high risk of gastrointestinal complications. The benefits of PPI therapy in preventing serious NSAID-related gastrointestinal events clearly outweigh the potential risks of long-term PPI use in this age group.