Many Nursing Home Residents Receive PPIs Inappropriately

Caroline Helwick

May 22, 2015

WASHINGTON, DC — Almost half of elderly residents in nursing homes who are prescribed proton pump inhibitors (PPIs) are receiving them without an evidence-based indication, according to a large database study presented here at Digestive Disease Week (DDW) 2015.

Of 1.5 million nursing home residents, 355,600 received at least one PPI. The main reason seemed to be for chronic cough, for which evidence of efficacy is lacking, said Pratik Rane, a doctoral candidate in the Pharmaceutical Health Outcomes and Policy program at the University of Houston, in Texas.

PPIs are used for various diagnoses, including ulcers and acid reflux disease. They are generally considered safe with very few adverse events, but recent literature has identified risks associated with their use, including pneumonia, fractures, and Clostridium difficile infections.

"If used appropriately, PPIs can have more benefits than risk," said Rane. "But given the safety concerns and high, non-evidence-based use of PPIs in nursing homes, there is an urgent need to optimize their use in the elderly."

Nursing home residents are already at increased risk for pneumonia and C. difficile infections, he pointed out.

National Nursing Home Survey

Rane reported findings from a retrospective cross-sectional study that examined data from the National Nursing Home Survey on nursing home residents.

Evidence-based indications for PPIs included those listed by the US Food and Drug Administration and the National Institute of Clinical Excellence guidelines from the United Kingdom's National Health Service.

The commonly used PPIs were pantoprazole (Protonix, Wyeth Pharmaceuticals Inc) (34.7%), lansoprazole (multiple brands) (34.1%), and omeprazole (multiple brands) (27%). Dexlansoprazole (Dexilant, Takeda Pharmaceuticals Co, Ltd) was not available at the time of the study.

"Among the elderly recipients of PPIs, 44.72% were prescribed the drugs without an appropriate indication," said Rane. The drugs most likely to be misprescribed were also those that were most commonly used – lansoprazole, omeprazole, and pantoprazole.

Inappropriate Use

In the multivariable logistic regression analysis, chronic cough was associated with the highest adjusted odds ratio (OR) for inappropriate use (OR, 2.62). Patients were less likely to receive them inappropriately if they had osteoporosis (OR, 0.59), which was a positive finding.

"Physicians were cautious in prescribing PPIs without an indication for patients with osteoporosis in the current study," Rane observed.

They were also less likely to be prescribed to patients receiving a selective serotonin reuptake inhibitor (OR, 0.83). However, this is a group that is at increased risk for upper gastroesophageal reflux disease. "Recent evidence supports the use of PPIs to limit such risk," he explained.

"Non-evidence-based use of PPIs was also high in the metropolitan statistical area, and this could be due to extensive prescribing of PPIs by physicians in those areas," he added.

Especially troubling is the high use of PPIs for chronic cough, said Rane. "PPIs could possibly be prescribed for underlying laryngopharyngeal reflux disease. There's a need for more evidence on their use for chronic cough due to acid reflux."

In an interview with Medscape Medical News, John Inadomi, MD, head of the Division of Gastroenterology at the University of Washington, in Seattle, wondered why this problem persists.

"Multiple studies, including some I have done, have looked at inpatient use of PPIs. The current study is novel in that it looked at nursing home residents, but we have been hearing about this problem for perhaps a decade," he pointed out.

Preset Orders to Blame

"Here's a new study showing the same thing happening — this is despite a lot of information, including preparation of physicians. But the situation has not improved. It's time for research to move into finding ways to do something about inappropriate use of PPIs," he said.

Dr Inadomi said it is possible that some PPI prescriptions are part of order sets. "It could be possible that a nursing home has a standard order set that puts patients on PPIs," he speculated. "We had an inpatient order set, and we took PPIs off the list. The physician then had to think about prescribing it. We found that inappropriate use dropped significantly."

Pratik Rane and Dr Inadomi report no relevant financial relationships.

Digestive Disease Week (DDW) 2015. Abstract 497. Presented May 18, 2015.

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