Darrell Hulisz, RPh, PhamD
Associate Professor, CWRU School of Medicine
Pharmacy Intern, Ohio Northern University
On October 9, 2015 the American Geriatric Society (AGS) publically released the updated Beers Criteria of Potentially Inappropriate Drugs. The Beers Criteria are used by clinicians in multiple settings to identify drugs to potentially avoid in the elderly. Many pharmacists use these guidelines to reduce adverse drugs events, improve medication selection and overall medication safety in older adults. The 2015 Beers Criteria have been greatly expanded to include alternative medications to use in the elderly, as well drug-disease and drug-drug interactions. Also included is a list of medications that may require renal dosage adjustment. The full guideline can be downloaded here:
A number of changes to the Beers Criteria were made for various drug classes, but one change with potential broad application to pharmacists involves the proton pump inhibitors (PPI). Examples of PPIs include omeprazole, esomeprazole, pantoprazole, and lansoprazole. Specifically the recommendation is to avoid use of PPIs beyond eight weeks in older adults, unless there is justification to continue use. Patients with high risk of gastrointestinal disease are excluded from this restriction, such as patients receiving long-term NSAIDs, those with Barrett's esophagus, hypersecretory conditions, or patients with a demonstrated need for ongoing PPI therapy.
According to the 2015 Beers Criteria consensus group, newer literate has demonstrated complications of PPI use that may be more common in the elderly. Concerns have been raised about PPI use and the development of acute interstitial nephritis, which may occur at any time during use. However, this is thought to be due to an idiopathic hypersensitivity reaction. Deficiency in magnesium or vitamin B12 may also occur with chronic PPI use, since both nutrients require stomach acidity for optimal absorption. Some researchers have speculated that oral absorption of other nutrients, such as calcium and iron salts may be impaired with chronic PPI use in the elderly.
Another reason cited for restricting PPI duration is the observation of increased risk for Clostridium difficile-associated diarrhea. This is thought to be related to a decrease in gut acidity, as stomach acid normally serves as a protection mechanism by killing potentially invading microorganisms. Additionally, osteoporosis-related bone fractures occur more frequently with PPI therapy, especially with long-term (≥ 1 year) or high-dose (≥ 1 dose / day) PPI therapy. In addition to osteopenia, fractures of the hip, spine, and wrist have been reported in association with chronic PPI use.
According to the Beers criteria, many elderly patients on PPI therapy should be transitioned to H2 (histamine-2) receptor antagonists, such as ranitidine and famotidine after 8 weeks of PPI treatment. This assumes that maintenance treatment is required for chronic reflux disease in low-risk patients.
- By the American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2015 Oct 8. doi: 10.1111/jgs.13702. [Epub ahead of print].
- Attwood SE, Ell C, Galmiche JP, Fiocca R, et al. Long-term safety of proton pump inhibitor therapy assessed under controlled, randomised clinical trial conditions: data from the SOPRAN and LOTUS studies. Aliment Pharmacol Ther. 2015 Apr 10. doi: 10.1111/apt.13194.
- Heidelbaugh JJ. Proton pump inhibitors and risk of vitamin and mineral deficiency. Ther Adv in Drug Safe 2013;4(3):125-133.