What is the efficacy and safety of using pantoprazole (Proton Pump Inhibitor) and chlorthalidone (Thiazide-like Diuretic) in a 65-year-old woman with Gastroesophageal Reflux Disease (GERD) and Hypertension?

From the Guidelines

For a 65-year-old woman with chronic GERD who has failed other treatments and also has hypertension, a combination of pantoprazole and chlorthalidone can be appropriate, but requires careful consideration. Pantoprazole (typically 40mg once daily) is generally well-tolerated in older adults for GERD management, with effectiveness for acid suppression and healing of esophagitis, as supported by the 2022 AGA clinical practice update on the personalized approach to the evaluation and management of GERD 1. For hypertension management, chlorthalidone (12.5-25mg once daily) is often preferred in older adults due to its long duration of action and proven cardiovascular benefits, as recommended by the 2017 American College of Cardiology/American Heart Association hypertension guideline 1. When using these medications together, monitoring is essential as PPIs like pantoprazole may slightly reduce the effectiveness of diuretics in some patients. Additionally, both medications require consideration of age-related changes in drug metabolism and elimination. Pantoprazole should be used at the lowest effective dose for the shortest duration necessary, as long-term PPI use in older adults has been associated with increased risks of bone fractures, C. difficile infections, and hypomagnesemia. Regular assessment of kidney function is important with chlorthalidone, as older adults are more susceptible to electrolyte disturbances, particularly hyponatremia and hypokalemia. Some key points to consider when treating hypertension in older adults include:

• The ACC/AHA guideline recommends a BP treatment threshold of 130/80 mm Hg or higher for pharmacologic treatment in older adults 1.
• Chlorthalidone is preferred over hydrochlorothiazide due to its longer therapeutic half-life and greater CVD risk reduction data 1.
• The benefits of treating both conditions typically outweigh these risks when appropriate monitoring is in place. It is also important to consider the patient's overall health status, including the presence of any comorbidities, and to individualize treatment accordingly. Overall, the combination of pantoprazole and chlorthalidone can be a effective treatment option for a 65-year-old woman with chronic GERD and hypertension, but requires careful consideration and monitoring to minimize potential risks.

From the FDA Drug Label

In short-term US clinical trials, EE healing rates in the 107 elderly patients (≥ 65 years old) treated with pantoprazole sodium were similar to those found in patients under the age of 65. The incidence rates of adverse reactions and laboratory abnormalities in patients aged 65 years and older were similar to those associated with patients younger than 65 years of age. The research does not provide direct information about using pantoprazole and chlorthalidone together in an older woman.

• Pantoprazole can be used in elderly patients (≥ 65 years old) for the treatment of chronic GERD, with similar healing rates and incidence of adverse reactions as in patients under 65 years old 2.
• There is no information about the combined use of pantoprazole and chlorthalidone in the provided drug label.
• Chlorthalidone is not mentioned in the provided drug label.

From the Research

Treatment of Chronic GERD

• Pantoprazole has been shown to be effective in treating chronic GERD, with studies demonstrating its ability to improve acid reflux-related symptoms, heal esophagitis, and improve health-related quality of life 3, 4.
• In older patients, GERD can be more severe and have more complications, making it important to consider aggressive treatment options 5, 6.
• Pantoprazole has been found to be safe and effective in special patient populations, including the elderly, and has a low incidence of drug interactions 3.

Comparison with Other Treatments

• Pantoprazole has been compared to other treatments, such as nizatidine, and has been found to be superior in producing complete heartburn relief and achieving erosion healing 7.
• Proton pump inhibitors, including pantoprazole, have been found to be more effective than histamine-2 receptor antagonists in treating GERD 4.

Considerations for Older Patients

• Older patients with GERD may have fewer symptoms, but their disease is often more severe and has more complications 5, 6.
• Early endoscopy is indicated in all elderly patients with GERD, regardless of symptom severity 6.
• The medical and surgical treatment of GERD in the elderly generally follows the same principles as for any adult patient 6.

Treatment of Hypertension

• There is no direct evidence in the provided studies regarding the use of chlorthalidone in combination with pantoprazole for the treatment of hypertension in an older woman with chronic GERD.
• However, it is common to use diuretics like chlorthalidone to treat hypertension, and proton pump inhibitors like pantoprazole to treat GERD, as part of a comprehensive treatment plan.