What is the recommended proton pump inhibitor (PPI) regimen for patients on steroid therapy?

PPI Regimen for Patients on Steroid Therapy

Patients on steroid therapy should receive a proton pump inhibitor (PPI) if they have risk factors such as age ≥65 years, previous gastrointestinal events, or concurrent use of NSAIDs, aspirin, or anticoagulants. 1

Risk Assessment and Indications for PPI Use

• Steroid therapy alone is considered a risk factor for gastrointestinal complications, with approximately a two-fold increase in gastrointestinal events compared to those not taking steroids 1
• PPI co-therapy is rated as "appropriate" for patients on steroids or warfarin according to expert consensus guidelines 1
• The decision to use PPI prophylaxis should be based on the presence of risk factors:
  • Age ≥65 years (2-3.5 fold increased risk) 1
  • Previous gastrointestinal events (2.5-4 fold increased risk) 1
  • Concomitant use of NSAIDs, aspirin, or anticoagulants 1
  • Higher doses of corticosteroids (>40 mg/day prednisone equivalent) 2

Recommended PPI Regimen

• Standard once-daily dosing of a PPI is recommended for most patients requiring gastroprotection while on steroid therapy 1
• There is no evidence supporting superiority of any specific PPI over others for steroid-induced gastroprotection 3
• Double-dose PPIs (twice daily or double-strength) are generally not recommended and have been associated with higher risks of complications including pneumonia, hip fracture, and C. difficile infection 1

Special Considerations

• For patients with additional risk factors (age ≥65 years with previous complicated GI events AND on steroids), PPI therapy is strongly recommended 1
• For patients <65 years with no previous GI events and on steroids alone, PPI therapy is still considered appropriate 1
• When steroids are combined with NSAIDs or aspirin, PPI therapy becomes even more important due to the additive risk 1

Duration of Therapy

• PPI therapy should be continued for the duration of steroid treatment 1
• After completion of steroid therapy, PPI should be discontinued unless there are other ongoing indications 1, 4
• Approximately 53% of patients started on PPIs during steroid therapy continue taking them after discharge, often unnecessarily for months (average 3 months) 4

Common Pitfalls to Avoid

• Unnecessary continuation of PPI therapy after completion of steroid treatment 4, 5
• Use of double-dose PPIs without clear indication 1
• Failure to consider drug interactions between PPIs and other medications 6
• Not recognizing that long-term PPI use carries potential risks including C. difficile infection, pneumonia, osteoporosis, and vitamin deficiencies 4, 5

Monitoring

• Regular reassessment of the need for ongoing PPI therapy is recommended 1
• For patients without a definitive indication for chronic PPI use beyond steroid therapy, consider de-prescribing once steroids are discontinued 1
• Document the indication for PPI therapy clearly in the medical record to facilitate appropriate discontinuation when no longer needed 1