Proton Pump Inhibitor Discontinuation in Long-Term Care Amy Linsky, MD, MSc, à w John A. Hermos, MD, à z Elizabeth V. Lawler, DSc, z § and James L. Rudolph, MD, SM k § OBJECTIVES: To determine factors associated with pro- ton pump inhibitor (PPI) discontinuation in long-term care. DESIGN: Retrospective cohort analysis. SETTING: Veterans Affairs (VA) long-term care facilities. PARTICIPANTS: Veterans admitted for nonhospice care in 2005 with a length of stay of 7 days or more who were prescribed a PPI within 7 days of admission (N 5 10,371). MEASUREMENTS: Prescribed medications and comor- bidities were determined from VA pharmacy and adminis- trative databases and functional status from Minimum Data Set records. Associations between participant charac- teristics and PPI discontinuation were determined using Cox proportional hazard ratios (HRs), censoring at death, discharge, or 180 days after admission. RESULTS: Participants were predominantly male (97%) and had a median age of 73 (interquartile range 60–81). There were 2,749 (27%) PPI discontinuations; 43% of these occurred within 28 days of admission. Hospitaliza- tions (HR 5 1.22, 95% confidence interval (CI) 5 1.01– 1.46), preadmission PPI use (HR 5 1.35, 95% CI 5 1.16– 1.56), and lowest functional status (HR 5 1.22, 95% CI 5 1.03–1.45) were associated with early PPI discontin- uation in adjusted models. Participants with gastric acid– related disease (HR 5 0.53, 95% CI 0.46–0.61), diabetes mellitus (HR 5 0.82, 95% CI 0.72–0.94), and those who were prescribed six or more medications (6–7 medications, HR 5 0.78, 95% CI 5 0.66–0.92; 8–10 medications, HR 5 0.64, 95% CI 5 0.54–0.76; 11 medications 0.51, 95% CI 5 0.42–0.62) were less likely to have early discon- tinuation. No PPI discontinuer had PPIs resumed during the study, and few (9%) had histamine-2 receptor antagonist substitutions. CONCLUSION: Although there may be clinical uncer- tainty regarding PPI discontinuation, more than one-quarter of participants prescribed a PPI upon admission to long-term care had it discontinued within 180 days. Targeting individ- uals prescribed PPIs for medication appropriateness review may reduce prescribing of potentially nonindicated medica- tions. J Am Geriatr Soc 59:1658–1664, 2011. Key words: long-term care; polypharmacy; proton pump inhibitors; prescriptions P roton pump inhibitors (PPIs), a class of medications frequently prescribed to residents of long-term care facilities, are used to suppress production of gastric acid. In the short term, PPIs are highly effective for treating gastric acid–related diseases such as gastroesophageal reflux, esophagitis, and gastric and duodenal ulcers. Although there are critical indications for long-term use (e.g., Bar- rett’s esophagus), chronic use is often not indicated. 1 PPI use without clear indication is common in people in hospi- tals, 2,3 and regardless of appropriateness of inpatient use, these individuals are then frequently discharged with a PPI prescription. 4 Although generally considered safe, recent observational studies have associated PPIs with risks of community-acquired and hospital-acquired pneumonia, Clostridium difficile infection, and osteoporotic frac- tures. 5–9 The associated morbidity of PPIs combined with the fragility of the long-term care population suggests that overuse of this medication class may disproportionately negatively affect these individuals. Discontinuation of unnecessary or ineffective medica- tions is challenging in long-term care settings, where res- idents take an average of seven to eight medications daily 10 and are at higher risk than older community-dwelling adults for adverse drug events and other medication-related complications. 11,12 However, the transition to a long-term care facility provides an opportunity to review and change prescribed medications under supervised conditions. 13 Considering the importance of these transitional periods and the fact that residents in long-term care are at high risk Address correspondence to Amy Linsky, 801 Massachusetts Avenue, 2nd Floor, GIM, Boston, MA 02118. E-mail: Amy.Linsky@bmc.org DOI: 10.1111/j.1532-5415.2011.03545.x From the à Section of General Internal Medicine, Department of Medicine, School of Medicine, Boston University, Boston, Massachusetts; w Center for Organization, Leadership and Management Research, z Massachusetts Vet- erans Epidemiology Research and Information Center, Veterans Affairs Co- operative Studies Program, and k Geriatric Research, Education and Clinical Center, Veterans Affairs Boston Healthcare System, Boston, Massachusetts; and § Division of Aging, Department of Medicine, Harvard Medical School, Boston, Massachusetts. JAGS 59:1658–1664, 2011 r 2011, Copyright the Authors Journal compilation r 2011, The American Geriatrics Society 0002-8614/11/$15.00