Proton pump inhibitors (PPIs) have their place but not without caution in the very young or the elderly, according to new recommendations on low value practice.

The Internal Medicine Society of Australia and New Zealand (IMSANZ) recommended medication reviews in over 65-year-olds on multiple medications across a wide range of agents.

President of the IMSANZ Dr Robert Pickles told the limbic appropriate de-prescribing could help reduce the risk of medication-related harm in the elderly.

 “We know that the more drugs you’re on, the greater the risk of a drug-drug interaction.”

 Older people also became more sensitive to the effects of any given medications – particularly as they lost weight and became frailer, he said.

Dr Pickles said patients were often started on PPIs for ‘a bit of indigestion’ and remained on them for many years despite never having gastroscopy-confirmed ulcerative oesophagitis.

“People with severe oesophagitis should be on them due to the risk of developing Barrett’s oesophagitis but we also see a lot of people who don’t fulfill that criteria.”

“We also know PPIs increase the risk of diarrhoea due to organisms such as C. difficile and contribute to further bone loss in people already osteoporotic.”

He recommended dietary manipulation to mitigate against reflux symptoms or switching patients to a trial of an H2-receptor antagonist.

“People should be aware that if they stop PPIs, they will get a rebound in reflux if they are not stopped in a staged manner.”

Meanwhile, the RACP’s Paediatrics & Child Health Division recommended against PPIs in infants and young children with uncomplicated gastroesophageal reflux or gastroesophageal reflux disease (GORD).

They said while there was some evidence for PPIs to treat GORD in older children, numerous trials had failed to show they were more effective than placebo in infants.

“Moreover, there is still a paucity of trials confirming the long term safety of PPI use in children more generally while there is considerable evidence that PPIs have significant negative side effects such headache, diarrhoea, constipation, nausea, increased rates of infection and increased rates of food allergy,” they said.

The recommendations were developed as part of the RACP’s EVOLVE program and the Choosing Wisely campaign.