Managing Proton Pump Inhibitor Use in Older Adults

Last Updated: August 30, 2021

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This tool is designed to help primary care providers assess and discuss with their patients 65 years of age or older, the potential benefits and risks of proton pump inhibitors (PPIs). This tool contains steps to support primary care providers in safely discontinuing, starting or continuing to prescribe PPIs for their older patients.

Many common indications for PPI use require short-term treatment. However, chronic use of PPIs has become problematic and rampant.1 PPIs are often viewed as safe and well-tolerated medications, and while the incidence of risks might be small, older adults are more susceptible due to comorbid conditions. When PPIs are inappropriately prescribed or used for too long, they can contribute to polypharmacy-related adverse reactions, medication errors, drug interactions, emergency department visits and hospitalizations.1

Potential risks from long-term ((≥ 1 year) use^
  • Increased risk of hip fracture2
    • NNH at 1 year = 4167 for women and 6667 for men3
  • Clostridium difficile infection2
    • NNH at 1 year = 10003
  • Acute interstitial nephritis4
  • Community-acquired pneumonia2
    • NNH at 1-6 months = 5563
  • Low levels of the mineral magnesium in the blood2
  • Vitamin B12 deficiency4
    • NNH at 1 year = 45
Potential benefits from short-term use6
  • Uninvestigated gastroesophageal reflux disease (GERD): heartburn remission
    • PPI 72% vs. placebo 25%, NNT at 1-12 weeks = 2*
  • Prevention of NSAID-associated peptic ulcer
    • PPI 14% vs. placebo 36%, NNT at >3 weeks = 4
  • Reflux (erosive) esophagitis
    • Acute healing: PPI 83% vs. placebo 28%, NNT at 8 weeks = 2*
    • Maintenance of healed esophagus: PPI 78% vs. placebo 21%, NNT at 8 weeks = 2*
    • Maintenance of symptom relief: PPI 71% vs. placebo 24%, NNT at 8 weeks = 2*
  • Endoscopy negative reflux disease: heartburn remission
    • PPI 38% vs. placebo 13%, NNT at 4-8 weeks = 4+
  • Functional (non-ulcer) dyspepsia: improvement in dyspepsia
    • PPI 34% vs. placebo 25%, NNT at 2-8 weeks = 10*
  • Helicobacter pylori eradication (HPE) for peptic ulcer disease: ulcer recurrence
    • Duodenal ulcer: HPE 13% vs. placebo 67%, NNT at ≤2 weeks = 2*
    • Peptic ulcer: HPE 16% vs. placebo 50%, NNT at 4-8 weeks = 3*

^ Due to the observational nature of the evidence, harms observed may be over-represented due to potential confounding
* Quality of evidence unclear
+ Moderate quality of evidence

Discuss with a patient their use of PPIs when a patient:
  • Is > 65 years of age
  • Comes in for a prescription renewal or refill
  • Has had a recent hospitalization
  • Has had a recent medication reconciliation
  • Is admitted to long-term care
  • Complains of side effects (headache, nausea, diarrhea and rash, etc.)
  • Is on medications that do not match their active medical concerns
Talking points
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Talking points

Address the patient’s PPI use

“What was the initial reason that you started the PPI and does that reason still exist?”

“If you no longer have symptoms, we can consider stopping the PPI.”

Tips for reviewing PPI use with patients
  • Set EMR reminders or patient record flags to review a patient’s PPI use during their next appointment.
  • Encourage patients to talk about their PPI use at their next appointment: 1) hand out patient material to patients ages > 65 or over; 2) put waiting room patient posters up; or, 3) provide screening questions while patients wait for their appointments. This type of patient material is available from the Canadian Deprescribing Network.7

Determine whether a PPI is appropriate or problematic1

Short term uses
  • Mild to moderate esophagitis or GERD
  • Peptic ulcer disease (from NSAID; H. pylori)
  • Upper GI symptoms without endoscopy
  • Uncomplicated H. pylori
  • ICU stress ulcer prophylaxis
Long term uses
  • Oral corticosteroids or chronic NSAID use
  • Severe esophagitis (Los Angeles grade C or D)4
  • Barrett’s esophagitis
  • Pathological hypersecretory condition
  • Demonstrated need for maintenance treatment (e.g. because of failure of drug discontinuation trial or H2-receptor antagonists)
  • Recurrent ulcers
  • Documented history of bleeding gastrointestinal ulcers1
  • Dual antiplatelet therapy (with a prior upper GI bleed or one other risk factor)4
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Discontinuing PPIs New

If taking a PPI is no longer appropriate for a patient, then use the following steps to help the patient taper off of the medication or taper to a lower dose.8

Tapering steps

Ensure that lifestyle changes and alternative therapies are implemented to reduce the risk of relapse symptoms during or following the taper (see Alternatives to PPIs)

There is no evidence that one tapering approach is better than another. The tapering plan should be based on patient preference and what plan seems most tolerable.

  • Engage patients in developing a clear plan for tapering
    • Find out when the patient’s symptoms are most severe and customize their tapering plan
  • Establish the method of tapering
    • Identify whether the Ontario Drug Benefit (ODB)14 covers the doses you plan to use during tapering (see PPIs available in Ontario) and if not, consider alternate-day dosing or switching to another PPI [that is covered]
    • Potential tapering methods:
      • Reduce the dose from twice daily to once daily8
      • Reduce the dose from daily to every second or third day8
      • Stop the PPI and replace it with H2 blockers
      • Reduce the dose to PRN
    • Include a note in the prescription to inform the pharmacist of the tapering plan
    • Consult the pharmacist if pill splitting is necessary to accommodate tapering doses and to discuss packaging options for older adults (e.g. dosette or blister pack)
  • Initiate the taper
  • Ask the patient to call in 2-4 weeks to report any relapse symptoms
    • Ask the patient if they are experiencing:
      • Heartburn
      • Reflux (used synonymously with heartburn)
      • Sore throat (i.e. difficulty swallowing)
      • New onset of coughing
      • Abdominal pain
    • Alternatively, if the patient is non-verbal, use a visual analogue scale (VAS) to identify pain or discomfort due to symptom relapse and look for signs of:9
      • Weight or appetite loss
      • Behavioural changes (e.g. agitation)
  • If the patient experiences withdrawal and/or rebound acid reflux, suggest using non-pharmacological and non-PPI pharmacological alternatives to lessen symptoms (see  Alternatives to PPIs)
    • If the patient does not tolerate the taper and the taper interferes with their normal activities, determine if the patient should return to a previous PPI dose
    • If the patient is still experiencing a recurrence of symptoms, test for H. pylori and contact a GI specialist for further consultation
Talking points
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Talking points

Emphasize the need to reduce polypharmacy
“I want you taking only the medications that you need. Let’s see if we can take you off unnecessary medications to help you feel better.”

Frame discontinuing PPIs as a trial
“Let’s try taking you off the PPIs to see how you feel? If any symptoms come back, you can tell me. We can always restart the dose that you need to feel comfortable.”

Reassure a patient that a PPI will be tapered instead of stopped completely
“Most patients are successful in tapering off of their PPIs. Sometimes, patients slowly decrease the dose to help their body adjust, but often, patients don’t notice a recurrence of their symptoms.”

Starting and continuing PPIs New

Starting PPI

For patients starting or continuing on a PPI, use the following information to ensure that the PPI is prescribed safely, considering individual patient factors.

Important information to collect before starting a PPI

  • Preexising conditions that require a GI referral:
    • Dysphagia10
    • Odynophagia10
    • GI bleeding/anemia10
    • Recurrent vomiting10
    • Weight loss10…
  • Dietary patterns and triggers (i.e. caffeine, alcohol, foods high in acid, nicotine)
  • All prescribed and over-the-counter medications that the patient is currently taking, including supplements, vitamins and naturopathic treatments (see Medications that interact with PPIs)
  • History of previous non-pharmacological (i.e. lifestyle changes) and pharmacological alternatives tried (see Alternatives to PPIs)
    • An adequate trial of non-pharmacological and pharmacological alternatives is approximately 6-8 weeks11…
  • History of adverse events

Tips for safe PPI prescribing

  • Ideally, limit a prescription to 2-8 weeks (high-risk patients might need more than 8 weeks; see Continuing PPI to identify high-risk conditions)
  • Discuss a tapering plan before prescribing a PPI
  • Consult with your local GI specialist before concomitantly administering antisecretory agents because of the marked reduction in acid inhibitory effects
    • Examples include, histamine-2 receptor antagonists (H2RAs), analogues of prostaglandin E (e.g. misoprostol) and somatostatin analogues (e.g. octreotide)12
  • Set EMR reminders or patient record flags to prompt you to revisit PPI use at the patient’s next visit and ask your patient to book a follow-up appointment within 4-8 weeks
Talking points
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Talking points

Provide instructions on when to take a PPI
“Take your PPI 30-60 minutes before you eat your breakfast in the morning, with a glass of water (not coffee), or before your last meal of the day.”

Discuss a tapering plan before prescribing a PPI
“We will start you on the PPI and then we will slowly decrease your dose once you start feeling better.”

Continuing PPI

First, it is important to determine if the chronic use of a PPI is warranted. Consider if the original indication for the PPI or ongoing risk factors for GI disease are present.

The following are high-risk conditions that may require long-term PPI use:
  • Barrett’s esophagitis13
  • Chronic oral corticosteroids or chronic NSAID use13
  • Grade C or D esophagitis4
  • Documented history of bleeding GI ulcers13
  • Dual antiplatelet therapy (with a prior upper GI bleed or one other risk factor)4

✓ Set annual EMR reminders or patient record flags to re-assess PPI use in patients with high-risk conditions.

Seek advice from a GI specialist for high-risk patients to assess ongoing risk factors.

PPIs available in Ontario

Scroll (left-right) for details
  • Dexlansoprazole* (Dexilant®)

    Type

    • Capsule

    Coverage

    • ODB X**

    Standard daily dose (healing)*

    • 30a mg or 60b mg

    Low daily dose (maintenance)

    • 30 mg

    Cost of 30-day supply of mean dosage*

    • $60-75
  • Esomeprazole*+ (Nexium®)

    Type

    • Tablet

    Coverage

    • ODB X**

    Standard daily dose (healing)*

    • 20c mg or 40d mg

    Low daily dose (maintenance)

    • 20 mg

    Cost of 30-day supply of mean dosage*

    • $45-60
  • Lansoprazole* (Prevacid®)

    Type

    • Capsule

    Coverage

    Standard daily dose (healing)*

    • 30 mg^

    Low daily dose (maintenance)

    • 15 mg^

    Cost of 30-day supply of mean dosage*

    • <$15
  • Omeprazole*+ (Losec®)

    Type

    • Capsule

    Coverage

    • ODB ✓
      • Some omeprazole is covered but is limited use38
      • All omeprazole magnesium is covered but is limited use38
      • 10 mg is not covered**

    Standard daily dose (healing)*

    • 20 mg^

    Low daily dose (maintenance)

    • 10 mg^

    Cost of 30-day supply of mean dosage*

    • <$15
  • Pantoprazole* (Tecta®, Pantoloc®)

    Type

    • Tablet

    Coverage

    • ODB ✓
      • Pantoprazole magnesium is covered39
      • Pantoprazole sodium is covered but is limited use39
      • 20 mg is not covered**

    Standard daily dose (healing)*

    • 40 mg

    Low daily dose (maintenance)

    • 20 mg

    Cost of 30-day supply of mean dosage*

    • <$15
  • Rabeprazole* (Pariet®)

    Type

    • Tablet

    Coverage

    • ODB ✓

    Standard daily dose (healing)*

    • 20 mg

    Low daily dose (maintenance)

    • 10 mg

    Cost of 30-day supply of mean dosage*

    • <$15

* = Standard dose PPI taken BID only indicated in the treatment of peptic ulcer caused by H. pylori; PPI should generally be stopped once eradication therapy is complete unless risk factors warrant continuing PPI
** = If the patient is on this PPI and needs to taper to smaller doses: stay at the higher dose but switch to alternating days OR contact the patient or their family/caregiver to see if they approve the cost of smaller doses
+ = available over the counter: Esomeprazole 20 mg (Nexium 24HR capsules) and Omeprazole 20 mg (Omep Acid Reducer capsules, Heartburn Control capsules and Riva brand omeprazole)
a = Symptomatic non-erosive gastroesophageal reflux disease, b = Healing of erosive esophagitis, c = Non-erosive reflux disease, d = Reflux esophagitis, ODB = Ontario Drug Benefit Program, ^ = Can be sprinkled on food
Note: reference to brand names does not imply endorsement of any of these products

Medications that interact with PPIs

Alternatives to PPIs New

Alternatives to managing GERD or esophagitis8

Non-pharmacological

Older adult patients can manage their GERD or esophagitis by incorporating the following lifestyle changes into their daily routines.8

Elevate the head of the bed (try placing a firm pillow between the mattress and the bed frame), particularly if nocturnal or laryngeal reflux symptoms are present18

Level of evidence •••

Modify diet:

  • Increase fibre intake to decrease heartburn19
  • Avoid chocolate, alcohol, caffeine, acidic citrus juices, large fatty meals, spicy food and peppermint18
  • Choose smaller quantities and eat slowly20

Level of evidence •••

Reduce body weight if BMI >30 kg/m2 or reverse recent weight gain18

Level of evidence •••

Avoid lying down for 2-3 hours after you eat18,21

Level of evidence •

Smoking cessation18

Level of evidence •

Avoid wearing tight clothing18

Level of evidence •

Level of evidence:
· · · · = meta-analysis or systematic review of randomized controlled trials
· · · = individual randomized controlled trial
· · = systematic review of cohort studies
· = individual cohort study or expert opinion

Talking points
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Talking Points

“Heartburn is common. This is why we have effective over-the-counter medicine to help, which are often safer options.”

“You may experience rebound symptoms, but they often go away with time and lifestyle changes. You can trial over-the-counter medication when you have rebound symptoms.”

“Avoid chocolate, alcohol, caffeine, acidic citrus juices, large fatty meals, spicy food and peppermint. All of these foods can give you heartburn. Try increasing your intake of fruits, vegetables, protein and complex carbohydrates.”22

Pharmacological

Medications with ODB14 coverage can be prescribed to patients if they are concerned about the cost of obtaining them over-the-counter. When possible and appropriate, eliminate drugs that impair esophageal motility and lower esophageal sphincter tone (e.g. anticholinergic agents, beta-adrenergic agonists, calcium channel blockers, theophylline and tricyclic antidepressants).18,31

Scroll (left-right) for details
  • Antacids
    Aluminum hydroxide/ magnesium hydroxide combinations (Diovol®)18,29

    Level of evidence ••••

    Coverage

    • ODB X

    Dose18

    • 30 mL (regular strength) PRN after meals

    Notes18

    • Avoid antacids containing magnesium or aluminum in renal dysfunction

    Side effects18

    • Constipation
    • Diarrhea
  • Alginates
    Aluminum hydroxide (Gaviscon® liquid)18,29

    Level of evidence ••••

    Coverage

    • ODB X

    Dose18

    • 10–20 mL PRN after meals

    Notes18

    • Alginates and some antacids contain significant amounts of sodium

    Side effects18

    • Nausea
    • Vomiting
    • Belching
    • Flatulence
  • Alginates
    Magnesium carbonate (Gaviscon® tablets)18,29

    Level of evidence ••••

    Coverage

    • ODB X

    Dose18

    • 2–4 tablets chewed PRN after meals followed by a drink of water

    Side effects18

    • Nausea
    • Vomiting
    • Belching
    • Flatulence
  • Histamine H2-receptor antagonists
    Cimetidine (Tagamet®)18,34

    Level of evidence •••

    Coverage

    • ODB ✓ (generic only)

    Dose

    • 400 mg twice daily16
    • If creatinine clearance level is <50 mL/min then reduce dose to avoid mental status changes27

    Side effects18

    • Diarrhea
    • Constipation
    • Headache
    • Fatigue
    • Confusion (most likely in older adults and those with poor renal function)
    • Cardiac effects
    • Rash
    • Gynecomastia (rare)
    • Impotence (rare)
  • Histamine H2-receptor antagonists
    Famotidine (Pepcid AC®, Pepcid AC Maximum Strength®)18,33

    Level of evidence •••

    Coverage

    • ODB ✓ (generic only)

    Dose

    • 20 mg twice daily16
    • If creatinine clearance level is <50 mL/min then reduce dose to avoid mental status changes27

    Notes18

    • Available without a prescription. Antacids may be given concomitantly if needed

    Side effects18

    • Diarrhea
    • Constipation
    • Headache
    • Fatigue
    • Confusion (most likely in older adults and those with poor renal function)
    • Cardiac effects
    • Rash
  • Histamine H2-receptor antagonists
    Nizatidine (Axid®)18,32

    Level of evidence •••

    Coverage

    • ODB ✓ (brand name only)

    Dose

    • 150 mg twice daily16
    • If creatinine clearance level is <50 mL/min then reduce dose to avoid mental status changes27

    Side effects18

    • Diarrhea
    • Constipation
    • Headache
    • Fatigue
    • Confusion (most likely in older adults and those with poor renal function)
    • Cardiac effects
    • Rash
  • Histamine H2-receptor antagonists
    Ranitidine* (Zantac, Zantac Maximum Strength®)18,35

    Level of evidence •••

    Coverage

    • ODB ✓ (generic only)

    Dose

    • 150 mg twice daily16
    • If creatinine clearance level is <50 mL/min then reduce dose to avoid mental status changes27

    Notes18

    • Available without a prescription.

    Side effects18

    • Diarrhea
    • Constipation
    • Headache
    • Fatigue
    • Confusion (most likely in older adults and those with poor renal function)
    • Cardiac effects
    • Rash

* = Currently unavailable in Canada due to the 2019 recall and contamination. Consult Health Canada and the FDA for updates.
ODB = Ontario Drug Benefit Program
Level of evidence:
· · · · = meta-analysis or systematic review of randomized controlled trials
· · · = individual randomized controlled trial
· · = systematic review of cohort studies
· = individual cohort study or expert opinion
Note: reference to brand names does not imply endorsement of any of these products.

Other alternatives

The following alternatives do not have the same efficacy as the non-pharmacological and pharmacological alternatives, but can alleviate minor symptoms of heartburn, reflux or stomach pain.

Scroll (left-right) for details
  • Bismuth subsalicylate (Pepto Bismol®)

    Side effects28

    • Salicylate toxicity
    • Black tongue
    • Black stool
    • Bismuth-induced encephalopathy
  • Calcium carbonate and magnesium hydroxide (Rolaids®)

    Side effects26

    • Hypercalcemia
    • Hypermagnesemia
    • Milk-alkali syndrome
    • Nephrolithiasis
    • Abdominal pain
    • Constipation
    • Dehydration
    • Diarrhea
    • Hypercalcemia
    • Hypercalciuria
    • Hypomagnesemia
    • Nausea
    • Vomiting
  • Calcium carbonate (Tums®)

    Side effects37

    • Constipation (most common)
    • Nausea (most common)
    • Hypercalcemia
    • Hypercalciuria
    • Renal calcification
    • Renal stones

    Notes

    • There may be an increased risk of MI with high supplement doses37
  • Magnesium hydroxide (Milk of Magnesia®)

    Side effects24

    • Hypermagnesemia in renal dysfunction

Note: reference to brand names does not imply endorsement of any of these products.

Resources New

Provider resources
Patient resources

References