Valuation of the Long-term Tolerance of Proton Pump Inhibitor (PPI) Discontinuation in Geriatric Patients Treated With Long-term Therapy Without a Recognized Indication
Valuation of the Long-term Tolerance of Proton Pump Inhibitor (PPI) Discontinuation in Geriatric Patients Treated With Long-term Therapy Without a Recognized Indication
Proton pump inhibitors (PPIs) are widely prescribed in France as anti-ulcer drugs. The indications currently approved in France, with variations according to molecules, are as follows: eradication of Helicobacter pylori, active peptic ulcer disease, maintenance treatment of duodenal ulcer disease, treatment of gastroduodenal lesions induced by non-steroidal anti-inflammatory drugs (NSAIDs), prevention of NSAID-induced gastro-duodenal lesions in at-risk subjects, symptomatic treatment of gastroesophageal reflux disease (GERD), esophagitis by GERD, maintenance treatment of esophagitis by GERD and Zollinger-Ellison syndrome.
Several misuse situations had been identified by the High Authority of Health (HAS) in its reassessment in 2009.
Although these molecules are very well tolerated in the short term, studies show the occurrence of long-term adverse effects such as an increase in the number of lung infections, Clostridium difficile infections and an increased risk of fractures.
Professor Sylvie Legrain, in a 2005 HAS report, described that "Better prescribing in the elderly is thus a public health issue. "Indeed, although multi-medication in the elderly is often justified, it increases the risk of drug iatrogeny, reduces compliance and has a significant cost to society. In this report, it is specified that digestive tract drugs (including PPIs) represent the 3rd most prescribed class of drugs for people over 65 years of age (17% of patients use them regularly). PPIs are also mentioned in this report as overuse (overtreatment).
The first study, conducted in 2017 at our centre (EGERIPP), sought to assess whether a rebound effect was observed in patients who stopped PPI therapy (if not indicated). In this study, 30 patients were included and no rebound effects were observed. Five patients resumed PPIs out of the 30 patients included (unexplored anemia - n=1, epigastric pain - n=1, gastroesophageal reflux disease - n=1, no justification found - n=2). For all patients, during reassessment on D14 and D21 (during hospitalization), patients did not report more symptoms after discontinuation. In this context, the investigators now wish to study whether the short-term tolerance is prolonged in the long term for the discontinuation of PPIs.
This first study also allowed us to assess the prevalence of PPI use in the elderly, and the prevalence of patients on PPI for a recognized indication. During the study, 270 patients were screened and 76 patients had a PPI at admission (28%). Of these 76 patients, no indication recognized by the HAS was found in the medical file for 63 patients (83%).
The discontinuation of PPI treatments in case of use outside the recommendations is usually carried out in the department where the study is being conducted. There is therefore no change in practices. On the other hand, it is good practice to discontinue a treatment that is prescribed outside the recommendations.
Following the EGERIPP study, the systematic reassessment of PPI treatments has become a service practice, with discontinuation when no recognized indication is found and prescription of antacids on demand.
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