**2. Material and methods**

It was about a retrospective study including 45 subjects of more than 65 years old followed in the external consultation of the gastroenterology department of Hédi Chaker hospital of Sfax, having consulting between July 01st, 2015 and December 31st, 2015. The PPI indication, the results of a possible initial endoscopic exploration, and their tolerance were specified by the data of the file. During the consultation, we realized an interrogation with the aim of checking the molecule's type, the dose, and the quality of the PPI observance. The criteria of inclusion were as follows: an upper age or equal to 65-year-old during the beginning of PPI treatment and PPI consumption at least three times a week during a duration of more than 12 months. The criteria of noninclusion were represented by the absence of an exhaustive list of the personal histories of patients and their medicines. The evaluation of the best use of the PPI was realized by referring to the current recommendations of the High Authority of Health and the French Agency of sanitary safety of the products of health (Afssaps) in 2007 [5]. The data were analyzed by using the statistical software SPSS 20.0.

### **3. Results**

The average age of our patients was of ±75 7 years (65–92). About 1/3 of the patients were less than 70 years old (**Figure 1**). In our study, a clear feminine predominance was noted with a sex ratio H/F of 0.4 (**Figure 2**). The majority of our patients were of urban origin (60%) (**Figure 3**). The distribution of the patients according to antecedent is specified as in **Table 1**. Excepting the pathology that justifies the PPI use, 25 patients (55.4%) had at least 3 medical antecedent with a daily average number of medicine consumption of 4.8 ± 4.3 (0–17). Six patients had osteoporosis, diagnosed before the establishment of the PPI in a case and after the establishment of the PPI in the five remaining cases. The average deadline separating the beginning of taking the PPI and the discovery of the osteoporosis was of 2.5 years (1–4). No control of the bone densitometry was asked during the follow-up of our patients who have a normal initial examination. Two patients (4.4%), with antecedent of ischemic heart disorder with angioplasty, were treated by clopidogrel (Plavix®) neither with any precaution's closed view to the type of the molecule nor with the schedule of taking PPI. During our interview, we recommended them to keep an interval of 12 hours between the consumption of the PPI and that of the clopidogrel. The main indication of the PPI at our patients was the gastroesophageal reflux (GER) (75.6%) (**Figure 4**). Before the prescription of the PPI, 41 patients (91%) underwent upper digestive endoscopy FOGD. The results of this examination were dominated by the association of a peptic esophagitis and a hiatal hernia (**Table 2**). Among the four remaining patients:


Five patients having a normal FOGD had:


serious and badly known, especially for the elderly person often fragile and exposed to a polypharmacy [4]. On the other hand, it is a very expensive therapeutic class and frequently used in an inappropriate way [2–4]. In Tunisia, the use of these medicines to the old subject, in the public structures, by specialists, was not studied. So, we have led this study to realize an evaluation of the professional practices concerning the prescription of these molecules, by gastroenterologists, in a teaching hospital (CHU) of the Tunisian South, to

**1.** Specify the main indications and the modalities of the long-term prescription of the PPI to

**2.** Evaluate the observance, the tolerance, and the possible medicinal interactions of the pre-

**3.** Specify, through our results and review of the literature, the difficulties were met and the risks incurred during the prescription of these medicines to the elderly and proposed strat-

It was about a retrospective study including 45 subjects of more than 65 years old followed in the external consultation of the gastroenterology department of Hédi Chaker hospital of Sfax, having consulting between July 01st, 2015 and December 31st, 2015. The PPI indication, the results of a possible initial endoscopic exploration, and their tolerance were specified by the data of the file. During the consultation, we realized an interrogation with the aim of checking the molecule's type, the dose, and the quality of the PPI observance. The criteria of inclusion were as follows: an upper age or equal to 65-year-old during the beginning of PPI treatment and PPI consumption at least three times a week during a duration of more than 12 months. The criteria of noninclusion were represented by the absence of an exhaustive list of the personal histories of patients and their medicines. The evaluation of the best use of the PPI was realized by referring to the current recommendations of the High Authority of Health and the French Agency of sanitary safety of the products of health (Afssaps) in 2007 [5]. The data were analyzed by using the statistical soft-

The average age of our patients was of ±75 7 years (65–92). About 1/3 of the patients were less than 70 years old (**Figure 1**). In our study, a clear feminine predominance was noted with a sex ratio H/F of 0.4 (**Figure 2**). The majority of our patients were of urban origin (60%) (**Figure 3**). The distribution of the patients according to antecedent is specified as in **Table 1**. Excepting the

the old subjects and compare them with the international recommendations.

scribed PPI in the long term to the elderly subjects.

egies to overcome them in our current practice.

the geriatric population.

132 Esophageal Abnormalities

The objectives of our study were:

**2. Material and methods**

ware SPSS 20.0.

**3. Results**

• A long-term treatment by nonsteroidal anti-inflammatory drug (NSAID) in a case.

**Figure 1.** Dividing patients according to the age.

**Figure 2.** Dividing patients according to sex.

**Figure 3.** Dividing patients according to their geographic origin.


**Table 1.** Dividing patients according to antecedents.

The FOGD data at five patients who had abdominal pain motivating the endoscopy were the following ones:


Gastric biopsies were realized in all the patients who had a bulbar ulcer or bulbar ulcerations. These biopsies were concluded with the absence of the helicobacter pylori in all cases. It was probably caused by the intermittent consumption of AINS in these patients. During the follow-up, only three patients had undergone an endoscopic control, having two peptic stenosis and one Barrett esophagus (BO). It revealed the disappearance of the stenosis in both patients and the absence of dysplasia in the third.

During the period of study (in July 01st, 2015–December 31st, 2015), the PPI availability in the pharmacy of the hospital and in the health centers was omeprazole in the form of 20 mg capsules. Concerning the years preceding the study's period, the molecules availability in the hospital list were either the omeprazole in the form of tablets or 20 mg capsules, or the lansoprazole in the form of 30 mg capsules.

However, these medicines were not always available in this pharmacy and\or in the pharmacies of health centers (frequent breaks of the stock). As a result, some patients would have used other molecules, which they had bought from nearby pharmacies. The interrogation of the patients and their parents was not able to specify the type of these molecules. The average duration of the PPI treatment was of 6 ± 4 years (1–16) with a duration of more than 2 years in 34 cases (75.6%). The PPI was prescribed at the rate of a simple daily dose for 29 patients (64.4%) and of a double daily dose for 5 patients (11.1%). For the rest of the patients, the treatment was prescribed:


**Figure 4.** Dividing patients according to PPI indications.

The FOGD data at five patients who had abdominal pain motivating the endoscopy were the

following ones:

• A bulbar ulcer in one patient

• Bulbar ulcerations in one patient

**Table 1.** Dividing patients according to antecedents.

**Figure 2.** Dividing patients according to sex.

134 Esophageal Abnormalities

**Antecedents N (%)** HTA 24 (53.3) Rheumatologic pathology 16 (35.6) Dyslipidemia 11 (24.4) Heart disease 9 (20) Diabetes 8 (17.7) Osteoporosis 6 (13.3) Anemia 2 (4.4)

**Figure 3.** Dividing patients according to their geographic origin.


**Table 2.** Dividing patients according to the data of initial FOGD.

The change of the PPI dose was indicated by the evolution of the symptoms motivating their prescription. So, the increase in doses was secondary in the persistence of the symptoms in spite of a good observance of a simple dose, whereas the decrease in doses was motivated by the decrease in the frequency of the symptoms under a double dose of treatment.

The characteristics of seven patients treated straightaway by an PPI double dose are detailed in **Table 3**. The recommendations of the HAS were not respected within the frameworks of:


The change of the PPI dose was indicated by the evolution of the symptoms motivating their prescription. So, the increase in doses was secondary in the persistence of the symptoms in spite of a good observance of a simple dose, whereas the decrease in doses was motivated by

The characteristics of seven patients treated straightaway by an PPI double dose are detailed in **Table 3**. The recommendations of the HAS were not respected within the frameworks of:

the decrease in the frequency of the symptoms under a double dose of treatment.

OP: peptic esophagitis; HH: hiatal hernia.

**Table 2.** Dividing patients according to the data of initial FOGD.

**Localization and types of lesions N (%)** Isolated esophageal lesions 8 (19.5) Peptic esophagitis OP 4 Peptic stenosis 2 Mycosic esophagitis 1 Barrett esophagus 1 HH/G isolated 1 (2.4) OP + HH 10 (24.4) Isolated gastric lesions: 7 (17.1) Congestive antral gastropathy 3 Ulcerated antral gastropathy 2 Nodular antral gastropathy 1 Pyloric big folds 1 Isolated duodenal infringement: 2 (4.9) UB 1 Bulbar ulcerations 1 Multiple locations of the lesions: 8 (19.5) HH + congestive antral gastropathy + bulbar ulcer 1 OP + HH+ bulbar ulcerations 2 OP + HH+ congestive antral gastropathy 1 OP + bulbar ulcerations 1 Ulcerated antral gastropathy + UB 2 HH + bulbar ulcerations 1 FOGD normal 5 (12.2) Total 41 (100)

136 Esophageal Abnormalities

○ Seven cases (15.5%) were treated straightaway by an PPI double dose. Indeed, according to the HAS recommendations, the interest of a double dose was not even demonstrated in RGO case with a severe esophagitis (except in not healing case and subject to a good observance of the treatment, where an increase in the posology can be proposed). So, no indication, among those of our patients, justifies an IPP treatment with one double dose straightaway. For the other cases, it was difficult to judge the concordance of posology with the recommendations against the difficulties of specifying the molecule's type of the prescribed IPP (omeprazole or lansoprazole), because the recommended posology, within the framework of our study's indications, is the full dose (or simple dose) for the omeprazole and the half-dose for the other molecules. The average duration of using PPI with our patients was of 6 ± 4 years (1–16). During the follow-up of our patients, the evaluation of PPI tolerance and the efficiency of the PPI, realized every 6 months, were based on anamneses data without any complementary examination. Furthermore, updating the antecedent list and the patients' treatments was not realized in a systematic way at every consultation. Among our patients, 31 (75.6%) had a good observance for the PPI. The nonavailability of the PPI in the public sanitary structures was the cause of the limited observance.


HH: hiatal hernia, GER: gastroesophageal reflux, NSAID: regular consumption of non steroidal anti inflammatory drugs OP type 2: peptic esophagitis type 2.

**Table 3.** Characteristics of patients treated by double dose (DD) of PPI.

The PPI did not cause any symptoms in 44 patients (97.7%). The remaining patients were presented after the consumption of lansoprazole double dose during 1 year (in front of a refractory GER) with profuse diarrhea. The colonoscopy revealed a normal colonic mucous membrane, but the colonic biopsies had revealed a microscopic colitis of colitis collagen type. Stopping the use of PPI has entrained the disappearance of the diarrhea. Because of the absence of treating the GER by famotidine in the dose of 40 mg/d, the patient was treated by the omeprazole in the dose of 20 mg/d). A few days after the beginning of the treatment, the evolution was marked by the reappearance of the diarrhea. So, the PPI was stopped. For the GER treatment, the patient was treated by a double dose of famotidine associated with the sodium alginate with a satisfying control of symptoms without diarrhea.
