What are the evidence‑based recommendations for prescribing a proton‑pump inhibitor in an elderly patient, including indication, dose, duration, monitoring, and deprescribing?

PPI Prescribing in Elderly Patients: Evidence-Based Recommendations

All elderly patients taking a PPI must have their indication documented and regularly reviewed by their primary care provider, with those lacking a definitive long-term indication considered for deprescribing, while those with high-risk features—particularly history of GI bleeding, concurrent anticoagulant/antiplatelet therapy, or severe erosive esophagitis—should continue therapy indefinitely. 1

Definitive Long-Term Indications (Continue PPI Indefinitely)

The following conditions justify indefinite PPI therapy in elderly patients:

• Barrett's esophagus 1
• Severe erosive esophagitis (LA Classification grade C/D) 1
• History of esophageal ulcer or peptic stricture 1
• History of upper GI bleeding while taking anticoagulants or antiplatelet agents 2, 3, 4
• Gastroprotection in patients ≥65 years taking NSAIDs with or without aspirin 3, 4
• Patients on dual antiplatelet therapy or multiple antithrombotic agents 3, 4
• Zollinger-Ellison syndrome 1

The appropriateness rating for PPI use increases by four points in patients ≥65 years compared to younger patients, reflecting strong expert consensus for gastroprotection in this age group. 3

Dosing Recommendations

Standard once-daily dosing is appropriate for most elderly patients:

• Pantoprazole 40 mg once daily 3, 4, 5
• Omeprazole 20 mg once daily 2
• Lansoprazole 30 mg once daily 2, 6

No age-based dose reduction is required in elderly patients. 3, 4 Take PPIs 30-60 minutes before meals for optimal efficacy. 2, 6

When to Consider Twice-Daily Dosing

Step down from twice-daily to once-daily dosing should be attempted in most patients currently on higher doses. 1 Twice-daily dosing is only justified for:

• Documented failure of once-daily therapy 1
• Complicated GERD with severe erosive esophagitis 1
• Pathologic hypersecretory conditions 6

Double-dose PPIs (standard dose twice daily) are not FDA-approved and increase risks of community-acquired pneumonia, hip fracture, and Clostridium difficile infection without proven additional benefit. 1

Duration of Therapy

Short-Term Indications (≤8 weeks)

• Uncomplicated GERD/dyspepsia: 4-8 weeks trial 1, 6
• Helicobacter pylori eradication: 14 days 1, 6
• Acute peptic ulcer disease: 4-8 weeks 1, 6

After 4-8 weeks, reassess response and consider deprescribing if symptoms have resolved and no long-term indication exists. 1, 2

Long-Term Therapy (>8 weeks)

Continue indefinitely only for definitive indications listed above. 1 For patients with PPI-responsive endoscopy-negative reflux disease who experience recurrence upon cessation, long-term therapy is conditionally indicated. 1

Monitoring Requirements

Mandatory Monitoring in Elderly Patients

The following should be monitored during long-term PPI therapy:

• Serum magnesium levels regularly, especially in patients on diuretics or digoxin, as PPIs increase risk of hypomagnesemia that can cause tetany, arrhythmias, and seizures 2, 5
• Renal function periodically, particularly in patients with CKD stage 4 or higher, as PPIs are associated with acute kidney injury and CKD progression 2, 5
• Vitamin B12 levels if treatment exceeds 3 years, as acid suppression causes malabsorption 5
• Bone density in patients at risk for osteoporosis, as PPIs increase fracture risk with long-term use 4, 5, 7

Documentation Requirements

Every PCP visit should include:

• Clear documentation of the ongoing indication for PPI use 1
• Assessment of whether the indication remains valid 1
• Consideration of deprescribing if no definitive long-term indication exists 1

Deprescribing Algorithm

Step 1: Identify Candidates for Deprescribing

Consider deprescribing in patients who:

• Have nonerosive reflux disease without sustained response to PPI 1
• Were started on PPI for unclear or undocumented indication 1
• Have been on PPI >12 weeks without documented chronic disease or risk factors 4
• Are taking PPI for stress ulcer prophylaxis after ICU discharge 7

Do NOT deprescribe in patients with:

• History of severe erosive esophagitis, esophageal ulcer, or peptic stricture 1
• Barrett's esophagus 1
• History of upper GI bleeding on anticoagulants/antiplatelets 2, 3, 4
• Ongoing need for gastroprotection (age ≥65 on NSAIDs/aspirin) 3, 4

Step 2: Deprescribing Method

For appropriate candidates, use gradual taper to minimize rebound acid hypersecretion:

1. Step down from twice-daily to once-daily dosing if applicable 1
2. After 2-4 weeks, reduce to every-other-day dosing 1
3. After 2-4 weeks, consider on-demand therapy (take only when symptomatic) 1
4. Monitor for symptom recurrence and reinitiate if definitive indication emerges 1

Special Considerations in Elderly Populations

High-Risk Elderly (Age ≥75 years)

Patients ≥75 years on aspirin, NSAIDs, steroids, or warfarin should receive indefinite PPI therapy due to dramatically elevated bleeding risk. 3, 4 This combination places patients in the "definitely indicated for long-term use" category. 3, 4

Renal Impairment

In patients with severe liver impairment (Child-Pugh C), reduce lansoprazole dose to 15 mg daily. 6 No dose adjustment is needed for pantoprazole or omeprazole in renal or hepatic impairment. 5

Drug Interactions

Pantoprazole exhibits the lowest potential for clinically relevant drug-drug interactions among PPIs, making it preferred in elderly patients with polypharmacy. 3 It does not significantly inhibit CYP2C19 and is compatible with cardiovascular medications including clopidogrel. 3

Take PPIs at least 30 minutes before sucralfate to avoid reduced absorption. 6

Adverse Effects Specific to Elderly

Long-term PPI use in elderly patients is associated with:

• Clostridium difficile infection: Higher risk in hospitalized elderly; use lowest dose and shortest duration 4, 5, 7, 8
• Osteoporotic fractures: Hip, wrist, and spine fractures increase with high-dose, long-term use (≥1 year) 4, 5, 7, 8
• Community-acquired pneumonia: Stronger association with higher doses 4, 7, 8
• Hypomagnesemia: Can occur after ≥3 months, most commonly after 1 year 2, 5
• Acute tubulointerstitial nephritis: Discontinue immediately if suspected 5
• Vitamin B12 deficiency: Consider after >3 years of therapy 5, 8
• Dementia: Observational associations exist but causality not established 8

Despite these associations from observational studies, randomized controlled trials have not shown higher rates of adverse events with PPIs versus placebo. 1 The key is ensuring a valid ongoing indication exists to justify the risk-benefit ratio.

Common Pitfalls to Avoid

Do not:

• Continue PPI indefinitely without documented indication 1
• Use twice-daily dosing without documented failure of once-daily therapy 1
• Combine PPI with H2-receptor antagonist (e.g., cimetidine) for routine GERD management 2
• Withhold PPI in elderly patients with history of GI bleeding on antithrombotics 2, 3, 4
• Prescribe empirically for laryngopharyngeal symptoms without documented reflux 1
• Discontinue abruptly in patients on long-term therapy (causes rebound hypersecretion) 9

Do:

• Document the specific indication at every visit 1
• Reassess need for continued therapy within 12 months of initiation 2
• Use standard once-daily dosing as first-line 1, 3, 4
• Monitor magnesium, renal function, and B12 in long-term users 2, 5
• Consider endoscopy in elderly patients with suboptimal response or early relapse 5

PPI Selection in Elderly

Any PPI is appropriate for most indications, but pantoprazole may be preferred in elderly patients with polypharmacy due to minimal drug interactions. 3 There is no clinically significant difference between individual PPIs for efficacy in standard indications. 3

Standard doses:

• Pantoprazole 40 mg daily 3, 4, 5
• Omeprazole 20 mg daily 2
• Lansoprazole 30 mg daily 2, 6
• Esomeprazole 20-40 mg daily 2