The Hospice Clinician Blog

In my original article, three years ago, I described the patterns of indiscriminate overuse of the proton pump inhibitor drugs (PPI medications) and cited some medical literature reports of increased risk of hip fracture and increased risk of infection related to their long-term use. At that time, I cautioned against the use of the PPI drugs for periods longer than 3 months for most patients and advocated for withdrawal of PPI therapy in any patient on long-term therapy that had not exhibited recent symptoms and had no established indication for continued use.   Now, the issue of PPI potential adverse effects is in the news again.

Fast-forward three years: Last month, the FDA issued a formal warning regarding the increased risk of fractures of the hip, wrist, and spine with long-term use of the PPI drugs (based on review of epidemiological studies). The majority of the studies evaluated individuals 50 years of age or older and the increased risk of fracture was primarily observed in this age group. The greatest increased risk for fractures in these studies involved people who had been taking prescription proton pump inhibitors for at least one year. FDA recommends healthcare professionals should consider whether a lower dose or shorter duration of PPI therapy would adequately treat the patient's condition.

An article in last year's American Journal of Gastroenterology (March 2009) amplified upon additional concerns associated with long-term PPI usage. The researchers from the University of Michigan, Department of Family Medicine, strongly advocated for clinicians to use the lowest dosage of PPI drug necessary for the shortest period of time to achieve the desired therapeutic goals. Concerns cited for their recommendation included the following risks; potential for Clostridium difficile-associated diarrhea, community acquired pneumonia, hip fracture, and vitamin B12 deficiency. The authors suggested the use of "step-down", or "on-demand" PPI therapy for treatment of GERD, and eliminating the use of PPI drugs for prophylaxis of "stress" ulcers outside of the ICU. 

The conclusion of the article in The Clinician Newsletter from 3 years ago is still appropriate today. Given the concerns over potential adverse effects, the documented overuse of these drugs, and the relatively high cost, clinicians should consider using these drugs at the lowest effective doses for the shortest possible durations. Serious consideration should be given to withdrawal of PPI therapy in any hospice patient on long-term therapy who has not exhibited symptoms within the previous 3 months and has no established indication for continued use.  

Some of the commonly used PPIs are listed below (many are now available in OTC formulations): Aciphex (rabeprazole), Nexium (esomeprazole), Prevacid (lansoprazole), Prilosec (omeprazole), Protonix (pantoprazole)

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