Proton pump inhibitors (PPIs) are prescribed for regular use to one in two residents of aged care services. |
There is a need to review whether indications for PPI use are still current when prescribing these medications for residents, and clearly document when PPIs are prescribed for gastroprotection in conjunction with specific gastric irritant medications. |
The opportunity exists to “step down” therapy and deprescribe PPIs in this setting. |
1 Introduction
2 Methods
2.1 Study Design, Setting, and Participants
2.2 Data Collection
2.3 Medication Use
Total daily dose of the PPI | |||
---|---|---|---|
Low dose (mg) | Standard dose (mg) | High dose (mg) | |
Pantoprazole | ≤ 20 | 40 | > 40 |
Omeprazole | ≤ 10 | 20 | > 20 |
Esomeprazole | N/A | 20 | > 20 |
Lansoprazole | ≤ 15 | 30 | > 30 |
Rabeprazole | ≤ 10 | 20 | > 20 |
2.4 Main Outcome Measures
2.5 Statistical Analyses
2.6 Compliance with Ethical Standards
3 Results
All residents (n = 383) | PPI use | |||
---|---|---|---|---|
No (n = 187) | Yes (n = 196) | P value | ||
Age, years, mean (SD) | 88 (6) | 87 (6) | 88 (6) | 0.42 |
Female (n, %) | 297 (76) | 141 (76) | 158 (79) | 0.46 |
High care needs (n, %) | 135 (35) | 72 (39) | 63 (32) | 0.19 |
Charlson Comorbidity Index score, median (IQR) | 2 (1–3) | 2 (1–3) | 2 (1–3) | 0.10 |
Dementia (n, %) | 169 (44) | 106 (57) | 63 (32) | < 0.001 |
Dementia severity rating scale score, mean (SD) (n = 380) | 19 (17) | 22 (18) (n = 186) | 16 (16) (n = 194) | < 0.001 |
FRAIL-NH score, mean (SD) (n = 379) | 4.70 (4) | 5 (4) (n = 185) | 4 (4) (n = 194) | 0.08 |
Activities of daily living score, mean (SD) (n = 378) | 3.4 (2) | 3.2 (2.3) (n = 184) | 3.6 (2.3) (n = 194) | 0.15 |
Number of regular charted medications, median (IQR) | 10 (7–13) | 8 (6–11) | 11 (9–14) | < 0.001 |
Medication regimen complexity index score, median (IQR) | 44 (33–56) | 40 (27–49) | 42 (37–61) | < 0.001 |
Neuropsychiatric Index scorea, median (IQR) | 2 (0–10) | 3 (0–12) | 2 (0–8) | 0.03 |
Any PPI, n (%) | PPI dosea | ||
---|---|---|---|
Standard or low dose, n (%) | High dose, n (%) | ||
Prescribed PPI | 196 (100) | 150 (77) | 45 (23) |
PPI type | |||
Pantoprazole | 97 (48) | 81 (54) | 14 (31) |
Omeprazole | 19 (9) | 14 (9) | 4 (9) |
Esomeprazole | 64 (32) | 35 (23) | 28 (62) |
Lansoprazole | 6 (3) | 6 (4) | 0 (0) |
Rabeprazole | 17 (8) | 14 (9) | 1 (6) |
Frequency of PPI use | |||
Once daily | 175 (89) | 147 (98) | 28 (62) |
Twice daily | 21 (10) | 3 (2) | 17 (38) |
More than twice daily | 0 (0) | 0 (0) | 0 (0) |
Pro re nata (when required) | 0 (0) | 0 (0) | 0 (0) |
Documented indication for PPI use | 145 (74) | 113 (75) | 32 (71) |
Indication for PPI use | |||
GERD | 121 (62) | 92 (61) | 29 (66) |
Esophagitis | 13 (7) | 12 (8) | 1 (2) |
Dyspepsia | 3 (2) | 3 (2) | 0 (0) |
Barrett’s esophagus | 5 (3) | 5 (3) | 0 (0) |
Peptic ulcer disease | 12 (6) | 9 (6) | 3 (7) |
Gastritis | 9 (5) | 8 (5) | 1 (2) |
Helicobacter pylori | 1 (1) | 0 (0) | 1 (2) |
Other | 5 (3) | 4 (3) | 1 (2) |
No. of residents with GERD or dyspepsia using PPI for > 8 weeks based on current medication chart | 93/123 (76) | 68/94 (72) | 25/29 (86) |
Concomitant medication associated with increased bleeding risk or gastric irritation | |||
NSAID or aspirin | 82 (42) | 62 (41) | 20 (44) |
NSAID | 14 (7) | 11 (7) | 3 (7) |
Aspirin | 73 (37) | 53 (35) | 20 (44) |
Oral anticoagulant | 26 (13) | 21 (14) | 5 (11) |
At least one of the above medications | 108 (55) | 82 (55) | 25 (56) |
Neither a documented indication nor medication associated with increased bleeding risk or gastric irritation | 23 (12) | 17 (11) | 6 (13) |
Response to PATD question | Total (n = 142) | PPI dosea | |
---|---|---|---|
Standard or low dose (n = 105) | High dose (n = 36) | ||
I feel that I am taking a large number of medications | 69 (49) | 50 (48) | 18 (50) |
I am comfortable with the number of medications that I am taking | 11 (8) | 8 (8) | 3 (8) |
I believe that all my medications are necessary | 107 (75) | 78 (74) | 28 (78) |
If my doctor said it was possible, I would be willing to stop one or more of my regular medications | 118 (83) | 87 (83) | 30 (83) |
I would like to reduce the number of medications that I am taking | 61 (43) | 46 (44) | 15 (42) |
I feel that I may be taking one or more medications that I no longer need | 25 (18) | 18 (17) | 7 (19) |
I would accept taking more medications for my health conditions | 85 (60) | 61 (58) | 23 (64) |
I have a good understanding of the reasons I was prescribed each of my medications | 96 (68) | 68 (65) | 27 (75) |
Having to pay for fewer medications would play a role in my willingness to stop one or more of my medications | 22 (15) | 15 (14) | 7 (19) |
I believe one or more of my medications are giving me side effects | 22 (15) | 14 (13) | 8 (22) |
Unadjusted odds ratio (95% CI) | Age and sex adjusted odds ratio (95% CI) | |
---|---|---|
Age | 0.96 (0.90–1.01) | 0.96 (0.91–1.01) |
Female | 0.66 (0.30–1.43) | 0.73 (0.33–1.61) |
High care needs | 0.52 (0.24–1.14) | 0.56 (0.25–1.23) |
Dementia | 0.71 (0.34–1.48) | 0.70 (0.33–1.48) |
FRAIL-NH scorea | 1.00 (0.92–1.09) | 1.01 (0.93–1.10) |
Activities of daily living scorea,b | 1.03 (0.89–1.19) | 1.01 (0.87–1.18) |
Number of regularly prescribed medications | 1.11 (1.01–1.21) | 1.11 (1.01–1.21) |
Medication regimen complexity index score | 1.02 (1.01–1.04) | 1.02 (1.01–1.04) |
Neuropsychiatric index scorec | 0.98 (0.95–1.02) | 0.98 (0.95–1.02) |
Documented indication for PPI use | 0.81 (0.38–1.70) | 0.80 (0.38–1.69) |
Gastroesophageal reflux disease (compared to absent or not documented) | 1.14 (0.57–2.29) | 1.12 (0.55–2.25) |
Other indications for PPI use (compared to absent or not documented) | 0.44 (0.13–1.55) | 0.46 (0.13–1.62) |
Concurrent medication use | ||
Oral non–steroidal anti–inflammatory drug or aspirin | 1.13 (0.58–2.22) | 1.05 (0.53–2.08) |
Oral anticoagulant | 0.77 (0.27–2.17) | 0.64 (0.22–1.86) |