What is the efficacy and safety of using famotidine (Proton Pump Inhibitor) and chlorthalidone (thiazide-like diuretic) in a 65-year-old woman with chronic Gastroesophageal Reflux Disease (GERD) and hypertension who has failed other treatments?

From the Guidelines

For a 65-year-old woman with chronic GERD requiring PPI treatment and hypertension, famotidine and chlorthalidone can be appropriate medications, but with important considerations. Famotidine (typically 20-40mg once or twice daily) is an H2 blocker that may be used as an adjunct to PPI therapy for GERD, but is not a substitute for a PPI in severe cases. For her hypertension, chlorthalidone (12.5-25mg daily) is an effective thiazide-like diuretic particularly beneficial in older adults, as supported by the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1. When using these medications together, monitor for electrolyte imbalances, particularly hypokalemia, which can occur with chlorthalidone and may be exacerbated by age-related kidney function changes, as noted in the European Society of Cardiology working group on cardiovascular pharmacotherapy review 1. Regular blood tests to check kidney function, electrolytes, and magnesium levels are important, especially during the first few months of treatment. Chlorthalidone should be taken in the morning to prevent nighttime urination, while famotidine is often most effective when taken before meals or at bedtime. Be aware that long-term PPI use in older adults carries risks including increased fracture risk, vitamin B12 deficiency, and potential kidney issues, so the lowest effective dose should be used, as recommended in the prevention, detection, evaluation, and management of high blood pressure in adults synopsis of the 2017 American College of Cardiology/American Heart Association hypertension guideline 1. Additionally, chlorthalidone may cause photosensitivity, so sun protection is advised. It is also important to consider the management of resistant hypertension, as outlined in the American Heart Association scientific statement on resistant hypertension: detection, evaluation, and management 1. Key considerations include:

• Monitoring for adverse effects, such as orthostatic hypotension and electrolyte disturbances
• Adjusting the dosing regimen to optimize BP control
• Considering the addition of other agents, such as mineralocorticoid receptor antagonists or beta-blockers, if necessary. Overall, the use of famotidine and chlorthalidone in this patient requires careful consideration of the potential benefits and risks, as well as regular monitoring to minimize adverse effects.

From the FDA Drug Label

Of the 1442 Famotidine-treated patients in clinical studies, approximately 10% were 65 and older. In these studies, no overall differences in safety or effectiveness were observed between elderly and younger patients In postmarketing experience, CNS adverse reactions have been reported in elderly patients with and without renal impairment receiving Famotidine Famotidine is known to be substantially excreted by the kidney, and the risk of adverse reactions to Famotidine may be greater in elderly patients, particularly those with impaired renal function In general, use the lowest effective dose of Famotidine for an elderly patient and monitor renal function

The use of famotidine in an older woman of 65 years old who needs PPI treatment for chronic GERD and hypertension is not directly addressed in the provided drug labels. However, the labels do provide information on the use of famotidine in elderly patients.

• Elderly patients with normal renal function can be treated with famotidine.
• Renal impairment is a concern in elderly patients, and dosage reduction is recommended in patients with moderate or severe renal impairment.
• CNS adverse reactions have been reported in elderly patients with and without renal impairment receiving famotidine.
• The labels do not provide information on the concomitant use of famotidine and chlorthalidone. Therefore, a conservative clinical decision would be to use the lowest effective dose of famotidine and monitor renal function in an elderly patient with chronic GERD and hypertension 2 2.

From the Research

Treatment of GERD and Hypertension in Older Adults

• The use of proton pump inhibitors (PPIs) is effective in the treatment of gastroesophageal reflux disease (GERD) in older adults, with studies showing that PPIs are superior to H2-receptor antagonists (H2RAs) in empirical treatment of typical GERD symptoms 3.
• For older adults with hypertension, the treatment goal is to lower blood pressure to less than 130/80 mmHg, with lifestyle measures plus antihypertensive drug therapy 4, 5.
• The choice of antihypertensive drug therapy in older adults should be based on clinical judgment, patient preference, and a team-based approach to assess risk/benefit, with no clear evidence to support recommendations for the use of particular antihypertensive-drug classes in older adults 4, 5.

Use of Famotidine and Chlorthalidone

• Famotidine is an H2RA that can be used in the treatment of GERD, but PPIs are generally more effective in reducing symptoms and preventing complications 3.
• Chlorthalidone is a diuretic that can be used in the treatment of hypertension, but its use in older adults should be based on individual patient characteristics and clinical judgment 4, 5.
• There is no direct evidence on the use of famotidine and chlorthalidone in combination in older adults with GERD and hypertension, but the available evidence suggests that PPIs and antihypertensive drug therapy can be effective in managing these conditions 4, 3, 5.

Considerations for Older Adults

• Older adults with GERD and hypertension may require a more aggressive approach to treatment due to the higher incidence of severe complications and comorbidities 6.
• The use of antihypertensive drug therapy in older adults should be based on individual patient characteristics, including the presence of comorbidities and the risk of adverse effects 4, 5, 7.
• The evidence suggests that conventional blood pressure targets may be appropriate for the majority of older adults, but additional research is warranted in those who are 80 years of age and older, and those who are frail 7.