Prolonged PPI Use in Older Adults with Osteoporosis or on Corticosteroids

Fracture Risk and Adverse Effects

The American Geriatrics Society recommends avoiding PPIs beyond 8 weeks in high-risk patients unless treating high-risk conditions like NSAID/corticosteroid-induced ulcer prevention, as prolonged PPI use increases fracture risk by approximately 20% 1
Meta-analysis of 24 observational studies demonstrates a 20% increased risk of hip fracture with PPI use, with the association strongest in patients with pre-existing risk factors including diabetes, kidney disease, and arthritis, particularly with ≥2 years of use 2
PPIs increase susceptibility to Clostridium difficile infection and gastroenteritis due to reduced gastric acid barrier 2
Community-acquired pneumonia risk is elevated, though hospital-acquired pneumonia risk is not 2
Vitamin B12 deficiency risk is a concern with long-term PPI use, although large RCTs showed no significant differences in serum B12 levels 2, 3
Iron deficiency risk exists with continuous PPI use, particularly after ≥1 year, as reduced gastric acid impairs non-heme iron absorption 2
Hypomagnesemia risk is 71% higher with PPI use, typically occurring after ≥3 months but most commonly after 1 year of therapy 2
Rebound acid hypersecretion is common after discontinuation of long-term PPI therapy, lasting 2-6 months 2

The American Gastroenterological Association identifies absolute indications where discontinuation of PPIs would cause more harm than potential adverse effects, including Barrett's esophagus, severe erosive esophagitis, and secondary prevention of gastric/duodenal ulcers in patients on NSAIDs/corticosteroids 2, 3
All patients without definitive indication for chronic PPI should be considered for trial of de-prescribing 2
The 2019 AGS Beers Criteria specifically flags PPIs as potentially inappropriate in older adults when used >8 weeks without high-risk indication 1

Use the lowest effective dose of PPIs, as dose-response relationship exists for fractures (higher doses = higher risk) 2
Consider periodic monitoring of magnesium levels, especially after 3-12 months of therapy 2
Assess B12 status in high-risk patients (elderly, those with additional malabsorption risk factors) 3
Monitor for iron deficiency, particularly in patients with baseline anemia or after ≥1 year of use 2