The Clinical Moment: Geriatrics and Deprescribing Proton Pump Inhibitors (PPI)
Why is patient taking a PPI?
If patient unsure – History of endoscopy? Hospitalization for bleeding ulcer? Heartburn or dyspepsia if on chronic NSAID?
Continue if Barrett’s esophagus, chronic NSAID use and bleeding risk, severe esophagitis, and documented history of bleeding GI ulcer
Recommend Deprescribing if Peptic ulcer Disease has been treated for 2-12 weeks (from NSAID; H. pylori), Upper GI symptoms without endoscopy; asymptomatic for 3 consecutive days, ICU stress ulcer prophylaxis treated beyond ICU admit, Uncomplicated H pylori treated x 2 weeks and asymptomatic, Mild to moderate esophagitis or GERD treated 4-8 weeks.
No evidence that one approach is better. Choose based on convenience and patient acceptance.
- Lower PPI dose - decrease frequency (BID to Daily), halving the dose or taking every second day.
- OR Stopping the PPI and use on-demand if symptoms return (taking daily until resolution achieved of reflux-related symptoms then stop).
Non-pharmacological approaches: Avoid meals 2-3 hours before bedtime, elevate head of bed, evaluate dietary triggers and consider weight loss if needed
To Manage Occasional Symptoms: OTC antacid, H2RA (ranitidine 150mg at bedtime or famotidine - may be less anticholinergic), PPI prn, alginate prn
Thoughts on other medications for GERD, PUD: Misoprostol may be option but may cause diarrhea (useful for decreasing constipation). Domperidone has cautions on doses greater than 30mg, increased cardiovascular events. Metoclopramide should be avoided due to EPS risk, unless for gastroparesis.