Proton pump inhibitors (PPIs) are commonly prescribed for the older person to treat acid-related conditions, including gastro-oesophageal reflux disorders, duodenal and gastric ulcers and eradication of helicobacter pylori. PPIs such as omeprazole and lansoprazole have many therapeutic benefits, but are not without risk. This research roundup will consider common adverse events experienced by the elderly when prescribed PPIs (Maes et al, 2017); an evaluation of methods to assess potentially inappropriate medicines, including PPIs (Sakr et al, 2018); and perspectives of patients and clinicians on conversations about their continued use (Thompson et al, 2018; Turner et al, 2018).
Adverse effects of proton pump inhibitor use in older adults: a review of the evidence
This article is a review of the literature, conducted by researchers in the USA (Maes et al, 2017). They reviewed published cohort studies, case controlled studies, randomised controlled trials and meta-analyses related to the older person (defined as people aged over 60 years). Six groups of adverse events were reported across 58 studies, namely bone fractures and falls (n=18), clostridium difficile infection (n=13), pneumonia (n=10), vitamin B12 deficiency (n=7), kidney disease (n=7) and dementia (n=4). Increased risk of bone fracture and falls appears to be one of the most commonly reported adverse events that led to recommendations that treatment should be as short as possible. The mechanism of action for this adverse event is not clear, but may be as a result of impaired calcium absorption, decreased bone density or higher risk of falls while using PPIs. It was also reported that older people who were prescribed PPIs may be at a greater risk of clostridium difficile infection due to an increase in gastric pH. Associations between use of PPIs and pneumonia were inconclusive, but the authors suggested that further research in this area was needed. A causal relationship between vitamin b12 deficiency and long-term PPI use has been reported, but associations between PPIs, kidney disease and dementia is less clear. This review has provided some insight into the risks and adverse events associated with long-term PPI use but, due to the observational nature of studies included, causal links cannot be made. Nonetheless, to reduce risk, the authors recommend that regular medication reviews should be conducted to evaluate the need for continued use of PPIs in the older person.
Assessment of potentially inappropriate medications in elderly and associations with treatment satisfaction
One approach to evaluating the need for continued use of PPIs is using a set of predetermined criteria to identify potentially inappropriate medicines (PIM). In a cross-sectional observational study (Sakr et al, 2018) with older people (n=350, mean age 72 years), the frequency of PIM using Beers criteria (Fick, 2019) and the screening tool of older people's potentially inappropriate prescriptions (STOPP) criteria was measured. In addition, data were collected on patient satisfaction using the treatment satisfaction questionnaire for medicines (TSQM). The study found that PPIs prescribed for more than 8 weeks were one of the most frequently inappropriately prescribed medicines for older people. With regards to treatment satisfaction, the study reported that older people were more satisfied with treatment when inappropriate medicines were deprescribed. The results of this study suggested that some older people were continued on medicines for longer than necessary and if not reviewed using a structured approach, this may result in both burdensome treatment and treatment dissatisfaction.
Patient values and preferences surrounding proton pump inhibitor use: a scoping review
This scoping review of 12 studies (Thompson et al, 2018) explored patient preferences of PPI use and deprescribing. The authors reported that symptom control and failure of lifestyle modifications had resulted in patients seeking PPI treatment, and that, once prescribed, patients reported concerns about dose and adverse events. A theme that emerged from the review was ‘attitudes towards deprescribing’, which suggested that patients were open to discussing and attempting a reduced dose, but were concerned about symptoms returning. The authors suggested that prescribers can mitigate these concerns by clearly communicate strategies for what to do if patients' symptoms return, and informing them that they can return to their previous dose if necessary. The next article in this roundup will present some research that has been conducted on approaches to deprescribing conversations.
Deprescribing conversations: a closer look at prescriber-patient communication
This qualitative study (Turner et al, 2018) took place in Quebec, Canada with 13 healthcare providers and 24 participants over the age of 65 years old who had been prescribed PPIs and benzodiazepines. It explored the effect of an educational intervention on a deprescribing consultation. In the intervention group, participants received an educational brochure before the medicines review. In the other group, the educational brochure was given after the consultation. All consultations between the health professional and patient were audio recorded and coded using MEDICODE, a structured and tested approach (Richard and Lussier, 2006). The coding consisted of 6 themes related to adherence, risk and adverse effects, attitudes, dosage, follow-up and drug efficacy. Participants in the group that received the education before the consultation were more likely to initiate a conversation relating to the MEDICODE themes and the conversation between the health professional became more of a two-way process. These findings suggested that when patients were provided with education before a consultation they were more likely to be engaged in a process of shared decision-making, a core component of effective prescribing practice. The study was small in scale and observational in nature but appeared to suggest that educating patients on what to ask before a medicines review might improve the quality and efficacy of a deprescribing consultation.
Conclusion
This roundup has provided recent, up-to-date evidence on the risks and adverse effects of PPI prescribing in the older person. The evidence presented suggested that adopting a structured approach, such as Beers criteria (Fick et al, 2019) to medicines review might reduce in inappropriate prescribing and improve treatment satisfaction. Qualitative literature suggested that patients were willing to reduce or amend treatment, provided that they had a strategy should symptoms return. Furthermore, research showed that empowering older people through a structured education programme before a medicines review could optimise medicines management. This evidence may encourage prescribers to not only consider using a structured approach to medicines review, but also to ask how they can empower patients to ask the right questions during a consultation. This may reduce both the medicines burden and the risk of adverse events in the older person who is prescribed PPIs.