Link found between PPIs and pneumonia in older people

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PneumoniaA large University of Exeter analysis has found a statistical link between pneumonia in older people and the use of proton-pump inhibitors (PPIs).

Although these are still a valuable group of medicines, research is indicating that PPIs are not as completely safe for older people as previously thought.

PPIs are medicines commonly prescribed to reduce gastric acid and to protect the stomach. Approximately 40% of older adults receive PPIs, although according to some experts, up to 85% of people who receive PPI prescriptions may not need them. Researchers say people should not stop using their PPI medication, but should discuss whether the PPIs are still needed with their prescribing healthcare professional. Just stopping PPIs could be dangerous as PPIs are very useful, for example for preventing stomach bleeds in some patients.

Once thought to be relatively harmless, PPIs have more recently been linked to increased rates for certain health concerns like fractures, cardiovascular disease, and some bacterial infections. The association between PPI use and pneumonia was studied because stomach acid is a barrier to infections spreading from the gut in people with stomach reflux. Since pneumonia is a major cause of death in this country for older adults, it is important for healthcare providers to understand the links between PPIs and pneumonia.

The Exeter team designed a study to look at statistical links between long-term PPI use and pneumonia in older adults in medical records.

David Melzer, professor of epidemiology and public health at the University of Exeter Medical School, said: “This study shows that there was a higher rate of pneumonia in older people who received PPIs over a two-year period. Caution is needed in interpreting the findings as our study is based on analysing data from medical records, so other factors may be involved. However, our study adds to growing evidence that PPIs are not quite as safe as previously thought, although they are still a very useful class of medication for certain groups of patients.”

The researchers used information from Clinical Practice Research Datalink (CPRD) for England, a large database containing records from many primary care practices in the UK. They selected patients 60-years-old and older who had taken prescribed PPIs regularly and who also had previous regular medical records. The researchers identified more than 75,000 older adults who were treated with PPIs.

As with all prescription medications, users should regularly review use of medicines like PPIs with healthcare providers to make sure each prescription is still needed. The researchers noted that patients should not stop taking PPIs themselves without consulting with healthcare professionals.

Objectives: To estimate associations between long‐term use of proton pump inhibitors (PPIs) and pneumonia incidence in older adults in primary care.
Design: Longitudinal analyses of electronic medical records.
Setting: England
Participants: Individuals aged 60 and older in primary care receiving PPIs for 1 year or longer (N=75,050) and age‐ and sex‐matched controls (N=75,050).
Measurements: Net hazard ratios for pneumonia incidence in Year 2 of treatment were estimated using the prior event rate ratio (PERR), which adjusts for pneumonia incidence differences before initiation of treatment. Inverse probability weighted models adjusted for 78 demographic, disease, medication, and healthcare usage measures.
Results: During the second year after initiating treatment, PPIs were associated with greater hazard of incident pneumonia (PERR‐adjusted hazard ratio=1.82, 95% confidence interval=1.27–2.54), accounting for pretreatment pneumonia rates. Estimates were similar across age and comorbidity subgroups. Similar results were also obtained from propensity score– and inverse probability–weighted models.
Conclusion: In a large cohort of older adults in primary care, PPI prescription was associated with greater risk of pneumonia in the second year of treatment. Results were robust across alternative analysis approaches. Controversies about the validity of reported short‐term harms of PPIs should not divert attention from potential long‐term effects of PPI prescriptions on older adults.

Jan Zirk-Sadowski, Jane A Masoli, Joao Delgado, Willie Hamilton, W David Strain, William Henley, David Melzer, Alessandro Ble

University of Exeter material
Journal of the American Geriatrics Society abstract

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