What are the guidelines for using Proton Pump Inhibitors (PPIs) in older adults with a history of gastroesophageal reflux disease (GERD) or peptic ulcer disease?

PPI Use in Older Adults with GERD or Peptic Ulcer Disease

Older adults with valid indications for PPIs—including GERD with severe erosive esophagitis, Barrett's esophagus, peptic ulcer disease, or those requiring gastroprotection with NSAIDs/antiplatelet therapy—should continue long-term PPI therapy, as the proven benefits substantially outweigh theoretical risks from observational studies. 1, 2

Valid Indications for Long-Term PPI Use in Older Adults

Older adults should continue PPIs for the following evidence-based indications:

• Barrett's esophagus (reduces esophageal adenocarcinoma risk) 2
• Severe erosive esophagitis (Los Angeles Classification grade C/D) 2
• History of peptic ulcer disease requiring secondary prevention 1, 2
• High-risk NSAID or aspirin users requiring gastroprotection 3, 2
• History of upper GI bleeding, especially with ongoing anticoagulant/antiplatelet therapy 1
• Eosinophilic esophagitis with PPI response 1, 2
• Idiopathic pulmonary fibrosis (prevents progression) 2

When to Consider Deprescribing

All older adults without a definitive indication for chronic PPI should be considered for a trial of deprescribing. 1, 2

Deprescribing Algorithm:

1. Review indication: Document whether a valid long-term indication exists 2
2. Assess bleeding risk: Patients with history of GI bleeding, multiple antithrombotics, or advanced CKD should not be deprescribed 1, 4
3. Step down dosing: Most patients on twice-daily dosing should be reduced to once-daily 1, 2
4. Discontinuation method: Either abrupt discontinuation or dose tapering are acceptable 2
5. Warn about rebound: Patients should expect transient upper GI symptoms lasting 2-6 months due to rebound acid hypersecretion 1

Evidence Quality on Long-Term Safety

The 2019 American Geriatrics Society Beers Criteria identifies PPIs as potentially inappropriate when used for >8 weeks without appropriate indication, citing increased risk of Clostridium difficile infection, bone loss, and fractures. 3

However, randomized controlled trials comparing PPIs with placebo have consistently shown no higher rate of adverse events among PPI users, while all studies reporting serious adverse events have been observational and cannot establish causality. 1, 2

Established Risks with Higher Probability:

• Enteric infections: Increased susceptibility to C. difficile colitis and gastroenteritis due to reduced gastric acid barrier (slight magnitude of risk) 1, 5
• Hypomagnesemia: Occurs after ≥3 months of use, most commonly after 1 year; meta-analysis shows 71% higher risk (adjusted OR: 1.71) 1, 5
• Acute tubulointerstitial nephritis: May occur at any point during therapy; discontinue if suspected 5
• Rebound acid hypersecretion: Common after discontinuation, lasting 2-6 months 1

Associations with Weaker Evidence:

• Fractures: Meta-analysis shows 20% higher hip fracture risk (RR: 1.20), but large RCTs found no difference 1
• Vitamin B12 deficiency: Dose-dependent association (>1.5 pills/day for ≥2 years), though 5-year RCTs showed no significant differences 3, 1
• Iron deficiency: Dose-dependent association after ≥1 year of continuous use 1
• Dementia: Only observational associations; no causality established in RCTs 2

Gastroprotection in High-Risk Older Adults

Older adults taking NSAIDs should use a PPI or misoprostol for gastrointestinal protection (high quality evidence, strong recommendation). 3

Patients taking COX-2 selective inhibitors with aspirin should use a PPI or misoprostol for gastrointestinal protection. 3

The 2009 JAGS guidelines emphasize that NSAIDs in older adults have absolute contraindications including chronic kidney disease and heart failure, with relative contraindications including hypertension and history of peptic ulcer disease. 3

Practical Management Principles

Dosing for GERD:

• Standard GERD: Once-daily PPI (omeprazole 20 mg or equivalent) 30-60 minutes before breakfast for 4-8 weeks 4
• Severe erosive esophagitis: Twice-daily high-potency PPI (esomeprazole 40 mg twice daily) 4
• All standard PPIs are clinically equivalent; selection should be based on cost and formulary considerations 4, 6, 7

Critical Pitfall to Avoid:

Discontinuing PPIs in older adults with definite indications based on concerns about unproven risks may lead to recurrent symptoms and serious complications, including upper GI bleeding. 1

Monitoring Recommendations:

• Use the lowest dose and shortest duration appropriate to the condition being treated 1, 5
• Monitor for hypomagnesemia, vitamin B12 deficiency, and acute kidney injury with long-term use 1, 5
• In older adults with osteoporosis risk factors, manage according to established treatment guidelines regardless of PPI use 1, 5
• Consider endoscopy in older patients with suboptimal response or early symptomatic relapse 5