Long-term proton pump inhibitor therapy and falls and fractures in elderly women: a prospective cohort study. Appropriate proton pump inhibitor use among older adults: a retrospective chart review. Proton pump inhibitors and vascular function: A prospective cross-over pilot study Risk Factors for Falls with Use of Acid-Suppressive Drugs Inappropriate prescribing of proton pump inhibitors in primary care On-demand PPI therapy in GERD Feasibility of a Patient-Centered Deprescribing Process to Reduce Inappropriate Use of Proton Pump Inhibitors
Proton pump inhibitors ( PPIs ) are widely used in the elderly . Recent studies have suggested that long-term PPI therapy is associated with fractures in the elderly , however the mechanism remains unknown . We investigated the association between long-term PPI therapy ≥1 year and fracture risk factors including bone structure , falls , and balance-related function in a post hoc analysis of a longitudinal population -based prospect i ve cohort of elderly postmenopausal women and replicated the findings in a second prospect i ve study of falling in elderly postmenopausal women .  Long-term PPI therapy was associated with increased risk of falls and fracture-related hospitalizations ; adjusted odds ratio ( AOR ) 2.17 ; 95 % CI , 1.25 - 3.77 ; p = 0.006 and 1.95 ; 95 % CI , 1.20 - 3.16 ; p = 0.007 , respectively . In the replication study , long-term PPI use was associated with an increased risk of self-reported falling ; AOR , 1.51 ; 95 % CI , 1.00 - 2.27 ; p = 0.049 . No association of long-term PPI therapy with bone structure was observed ; however , question naire-assessed falls-associated metrics such as limiting outdoor activity ( p = 0.002 ) and indoor activity ( p = 0.001 ) due to fear of falling , dizziness ( p < 0.001 ) and numbness of feet ( p = 0.017 ) and objective clinical measurement such as Timed Up and Go ( p = 0.002 ) and Romberg eyes closed ( p = 0.025 ) tests were all significantly impaired in long-term PPI users . Long-term PPI users were also more likely to have low vitamin B12 levels than non-users ( 50 % versus 21 % , p = 0.003 ) . In conclusion , similar to previous studies , we identified an increased fracture risk in subjects on long-term PPI therapy . This increase in fracture risk in elderly women , already at high risk of fracture , appears to be mediated via increased falls risk and falling rather than impaired bone structure and should be carefully considered when prescribing long-term PPI therapy BACKGROUND Proton pump inhibitors ( PPIs ) are widely used , but not always with a clear indication . Nonindicated use is of particular concern among older adults , who may have multiple comorbidities and take more medications , increasing their risk for adverse drug reactions . OBJECTIVE This study examined the appropriateness of PPI use at an outpatient geriatric practice and the association between particular patient characteristics and appropriate use of these medications . METHODS This was a retrospective chart review of a group of r and omly identified community-dwelling adults aged > or=65 years with a current prescription for a PPI ( as of August 2006 ) from a geriatric ambulatory care practice within an urban academic medical center . The main outcome was appropriateness of PPI use , categorized as indicated , possibly indicated , or not indicated , based on US Food and Drug Administration-approved indications and national gastroenterology guidelines . RESULTS Out of approximately 2500 patients in the geriatric practice , 702 ( approximately 28 % ) were identified as having a current prescription for a PPI .  From these , 110 charts were r and omly selected for review , of which 10 were excluded based on predefined criteria . The sample was 79 % female and 46 % white , with a mean age of 82.8 years ( range , 66 - 99 years ) .  PPI use was indicated in 64 % of these patients , possibly indicated in 7 % , and not indicated in 29 % . Compared with indicated PPI use , nonindicated use was significantly associated with use for < 1 year ( relative risk = 2.20 ; 95 % CI , 1.00 - 4.86 ; P = 0.05 ) . Nonindicated PPI use was not significantly associated with age , female sex , nonwhite race , or PPI initiation in the inpatient setting . CONCLUSION Almost 30 % of patients receiving a PPI  in this academic geriatric practice had no documented indication for PPI use Proton pump inhibitors ( PPIs ) are commonly used drugs for the treatment of gastric reflux . Recent retrospective cohorts and large data base studies have raised concern that the use of PPIs is associated with increased cardiovascular ( CV ) risk . However , there is no prospect i ve clinical study evaluating whether the use of PPIs directly causes CV harm . We conducted a controlled , open-label , cross-over pilot study among 21 adults aged 18 and older who are healthy ( n=11 ) or have established clinical cardiovascular disease ( n=10 ) . Study subjects were assigned to receive a PPI ( Prevacid ; 30 mg ) or a placebo pill once daily for 4 weeks . After a 2-week washout period , participants were crossed over to receive the alternate treatment for the ensuing 4 weeks . Subjects underwent evaluation of vascular function ( by the EndoPAT technique ) and had plasma levels of asymmetric dimethylarginine ( ADMA , an endogenous inhibitor of endothelial function previously implicated in PPI-mediated risk ) measured prior to and after each treatment interval . We observed a marginal inverse correlation between the EndoPAT score and plasma levels of ADMA ( r = −0.364 ) . Subjects experienced a greater worsening in plasma ADMA levels while on PPI than on placebo , and this trend was more pronounced amongst those subjects with a history of vascular disease . However , these trends did not reach statistical significance , and PPI use was also not associated with an impairment in flow-mediated vasodilation during the course of this study . In conclusion , in this open-label , cross-over pilot study conducted among healthy subjects and coronary disease patients , PPI use did not significantly influence vascular endothelial function . Larger , long-term and blinded trials are needed to mechanistically explain the correlation between PPI use and adverse clinical outcomes , which has recently been reported in retrospective cohort studies Background : Some recent reports suggest an increased risk of fractures with use of proton pump inhibitors ( PPIs ) and histamine type 2 receptor antagonists ( H2RAs ) , although results are inconsistent and a causal relationship has yet to be proven . As these acid-suppressive drugs may have uncommon adverse effects on the central nervous system ( CNS ) , such as dizziness , we investigated whether their use is associated with falls as a possible mechanism for increasing fracture risk . Methods : A cohort study with nested case-control analysis and two validation strategies was performed using data from UK patients ( aged 40–89 years ) included in The Health Improvement Network data base ( 2000–2008 ) . Due to the large number of falls , a r and om sample of 20,000 cases was used for the analysis . Results : The overall incidence of falls per 1000 person-years was 13.0 ( 95 % confidence interval [ CI ] = 12.9–13.1 ) . After adjustment for potential confounders , there was no relationship between falls and current use of single PPIs ( odds ratio [ OR ] = 0.95 ; 95 % CI = 0.89–1.02 ) or H2RAs ( OR = 1.01 ; 95 % CI = 0.90–1.14 ) ; there was no relationship with dose or duration of treatment . Falls were associated with CNS disorders and treatment with various pharmacological agents including antiparkinson drugs ( OR = 2.7 ; 95 % CI = 2.2–3.3 ) and antiepileptics ( OR = 2.1 ; 95 % CI = 1.8–2.3 ) . Conclusions : There was no association between falls and use of PPIs or H2RAs . Any potential increase in the risk of fractures proposed to be associated with the use of acid-suppressive drugs is not via an increased risk of falls Objectives : To determine if an educational intervention initiated in secondary care can influence prescribing of proton pump inhibitors  ( PPIs ) in the community . Methods : A prospect i ve study of  PPI use in patients admitted to medical wards in a university hospital . A simple educational intervention was employed to reduce inappropriate prescribing of PPIs in the community . Results : In the pre-intervention analysis 66/271 ( 24 % ) patients were receiving treatment with a PPI prescribed in the community . In 36/66 ( 54 % ) patients the PPI had been prescribed inappropriately . Six months after the intervention 91/344 ( 26 % ) patients were prescribed a PPI in the community . In only 45 of these 91 ( 49 % ) patients was there a recommended indication . Conclusion : The intervention used in this study had no effect on the proportion of patients taking a PPI  at the time of hospital admission or on the appropriateness of prescribing in the community Opinion statementConsiderable clinical experience with proton pump inhibitors ( PPIs ) attests to their efficacy and safety in short- and long-term therapy for gastroesophageal reflux disease ( GERD ) in erosive esophagitis and endoscopy-negative ( NERD ) patients . One alternative to continuous PPI maintenance is PPI therapy administered noncontinuously ( eg , “ on dem and ” ) . Qualities of good PPI therapy for such a modality should include fast and sustained acid suppression . The newer-generation PPI esomeprazole has provided greater acid inhibition . R and omized controlled clinical trials comparing ondem and PPI versus placebo or versus continuous PPI therapy in GERD patients have shown that on-dem and therapy with currently available PPIs ( esomeprazole in particular ) appears to be effective in the long-term management of patients with NERD or mild esophagitis and uninvestigated forms of GERD , who make up the overwhelming majority of patients with GERD . This is because it is safe and provides adequate symptom control and sustains quality of life . However , it is not indicated in patients with severe erosive esophagitis or with complicated esophagitis ( ie , Barrett ’s esophagus or stricture ) . On-dem and PPI therapy is important for economic reasons , as it may save up to two thirds of daily doses of the drugs , with a considerable containment of drug expenses . For a long-term disease whose treatment is aim ed primarily at symptom control , it is a sensible and cost-effective approach Background : Proton pump inhibitors ( PPIs ) are inappropriately prescribed in up to 50 % of users . Systematic medication review and cessation of inappropriate medications or deprescribing may improve patient outcomes and reduce costs . Objective : The aim of this study was to assess the feasibility of a patient-centered deprescribing process in a population of adults with complex polypharmacy . Methods : This was a prospect i ve feasibility study . Participants were recruited from hospital outpatient clinics . The patient-centered deprescribing process consisted of 5 steps : comprehensive medication history , identification of potentially inappropriate medications , determining if the medication can be ceased , planning the withdrawal regimen ( eg , tapering where necessary ) , and provision of monitoring , support , and documentation . Feasibility was determined by assessing time taken to complete the different steps of the deprescribing process and participant feedback . Results : In all , 57 PPI users were recruited ; participants were 70 ± 14 years old and took 14 ± 6 medications . The indication for PPI use was verified in 43 participants and judged as potentially inappropriate in 19 ( 44 % ) ; 8 were suitable for trial withdrawal , and 6 consented . All 6 successfully ceased ( n = 3 ) or reduced ( n = 3 ) their PPI use , and this was sustained at 6 months postintervention in 4 participants . Conclusions : The patient-centered deprescribing process can safely reduce inappropriate PPI prescribing in a small proportion of people . Although the process was acceptable to participants , difficulties in accessing complete medical histories , time limitations , and minimal evidence to support effectiveness in certain indications were barriers to implementation of the process in clinical practice
Conclusions We demonstrate a significant association between the use of PPIs and increased risk of fall .
In addition , there is potentially higher risk of fall among PPIs users over time
Background Fall prevention among older adults is a worldwide public health advocacy because of negative consequences of fall .
Recent studies have shown that proton pump inhibitors ( PPIs ) increase the risk of fall .
PPIs are among the widely prescribed medications oftentimes without clear indications .
Concerns for safety of long-term use of PPIs have been raised by numerous studies .