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Factors associated with the initiation of proton pump inhibitors in corticosteroid users


J. C. Munson, Section of Pulmonary and Critical Care Medicine, Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH 03756, USA. E-mail:



Proton pump inhibitors (PPIs) and corticosteroids are commonly prescribed drugs; however, each has been associated with fracture and community-acquired pneumonia. How physicians select patients for co-therapy may have implications for potential additive or synergistic toxicities.


We conducted a retrospective cohort study of 13 749 incident corticosteroid users with no prior PPI exposure using the HealthCore Integrated Research DatabaseSM. We used logistic regression to evaluate the association between PPI initiation in the first 30 days of steroid therapy and corticosteroid dose, clinical risk factors including comorbid diseases, and medication use including prescription nonsteroidal anti-inflammatory drugs (NSAIDs).


A new PPI prescription within 30 days of starting corticosteroids was filled by 1050 patients (7.6%). PPI use was associated with the number of baseline comorbid conditions (OR = 1.21 for each additional condition, 95%CI = 1.13–1.28), recent hospitalization (OR = 4.71, 95%CI = 4.02–5.52), prednisone dose higher than 40 mg/day (OR = 1.87, 95%CI = 1.45–2.41), history of gastroesophageal reflux or gastric ulcer disease (OR = 1.54, 95%CI = 1.24–1.91), renal insufficiency (OR = 2.06, 95%CI = 1.73–2.46), and liver disease (OR = 1.82, 95%CI = 1.45–2.28). The concomitant use of prescription NSAIDs was also associated with PPI use (OR = 1.89, 95%CI = 1.32–2.70); however, the total use of PPIs in this group was low (6.3%, 95%CI = 4.4–8.2%).


Overall, PPI therapy among corticosteroid users was uncommon, even among those with risk factors for gastrointestinal toxicity. PPI use was significantly more common among patients who had recently been hospitalized, had a greater burden of comorbid illness, or were receiving high daily doses of corticosteroids. Copyright © 2012 John Wiley & Sons, Ltd.