A Caution on Acid-Reducers for Older Patients...

They’re among the most widely prescribed medications in the world. They’re reasonably safe for most people to take. That’s why drugs that reduce stomach acid — used to combat heartburn, acid reflux and ulcers — don’t get much scrutiny from doctors, or from patients.
Tony Cenicola/The New York Times Popular acid-inhibitors: Zantac 75, center, with Prilosec and Tagamet HB 200.
“When patients were admitted to our geriatric wards, a lot of them didn’t have clear indications for taking these drugs,” said Dr. Ian Logan, a Scottish physician and co-author of a recent editorial on acid suppressants in the journal Age and Ageing. “And they’d remained on them for a lot longer than they should have.” One of his patients had been taking an acid reducer for 15 years.
Dr. Logan and two colleagues with Britain’s National Health Service decided to sound the alarm — rather, to sound it once more, as researchers began discovering problems with these drugs years ago. “They do have significant side effects, especially in older patients,” Dr. Logan told me in an interview.
The drugs he was talking about fall into two categories: the H2 receptor antagonists introduced in the 1970s (marketed in the United States as Zantac, Tagamet and Pepcid) and the more potent proton pump inhibitors (P.P.I.’s include Prevacid, Protonix, Prilosec and Nexium) that became available in the late 1980s.
Studies have linked P.P.I.’s to an increased risk of pneumonia, and both drugs to gastrointestinal infections. Perhaps, researchers suggest, reducing stomach acid removes an important barrier against pathogens. Particularly worrisome, Dr. Logan added, is an association between P.P.I.’s and the rising outbreaks of Clostridium difficile infections; the C. difficile bacterium, resistant to many antibiotics, can cause serious diarrheal illness.
Several studies also have shown an increased risk of bone fractures from osteoporosis in patients taking P.P.I.’s, though the results aren’t consistent. Possibly the change in stomach acidity reduces the body’s ability to absorb calcium.
Pneumonia, infections, fractures — “As patients get older, they have increased risk of all these things,” said Randolph Regal, a pharmacy professor at the University of Michigan. “In spite of that, the misuse of these medications appears to continue.”
He should know: In 2006, Dr. Regal and his colleagues published a study of 213 patients admitted to the University of Michigan Hospital. While only 29 percent were previously taking acid suppressants, more than 70 percent used them after they entered the hospital and more than half still took them when they were discharged. Yet only 30 percent of those patients had a condition, like peptic ulcers or acid reflux disease, that called for acid-reducing drugs.
“They can be used indiscriminately for any ache between someone’s chin and knees,” said Dr. Nicholas Shaheen, a specialist in esophageal diseases at the University of North Carolina, Chapel Hill.
“If people are taking them for appropriate reasons, we don’t want them to stop,” Dr. Logan warned. What makes sense, though, is for users and their doctors and pharmacists to regularly review these prescriptions with an eye to using the medications intermittently, reducing the dose or perhaps discontinuing them altogether.
“These are very useful drugs and they’ve revolutionized how we treat acid-related diseases,” Dr. Logan said. “But they’re not as safe as we think they are.”

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