Management of GERD in the elderly with pantoprazole Table 1 Rates of long-term PPIs use References Country Deﬁnition Ryder et al 1994 UK Six months or more Chen et al 2003 Roberts and Bateman 1995 UK All PPI prescribing in a deﬁned period Rubin et al 1995 UK >12 months Goudie et al 1996 UK Repeat prescribing register Boutet et al 1999 Sicily, UK Repeat prescribing register Hungin et al 1999 UK 6 months or more Prach et al 1999 UK More than 56 days/year Roberts and Bateman 1995 Vetvick and Straand 2001 Norway ddu Jacobson et al 2003 Ahnfeldt-Mollerup et al 1997 Denmark Constant treatment Hurenkamp et al 2002 Holland More than 12 weeks Tsai et al 2004 Chen et al 2003 Taiwan Prescription items and ddu Jacobson et al 2003 USA More than 90 days Raghunath and Hungin 2004 UK Six months or more Lassen et al 2004 Denmark >180 ddu/year Majumdar et al 2003 USA Equal to or more one year Abbreviations: ddu, daily deﬁned units; GP, general practitioner; PPIs, proton pump inhibitors. Population size 60 148 41 GP practices 24 400 15 495 42 GP practices 46 650 35 000 17 105 7160 46 813 / 168 727 46 933 470 000 216 720 of GERD and asthma after discontinuation of treatment is not known. PPIs, and among them pantoprazole, produce superior symptomatic remission rates and clinical efﬁcacy compared with H2 antagonist (such as ranitidine). Moreover pharmacokinetic considerations suggest that H2 antagonist present a progressive phenomena of tolerance with continuous administration, leading to a consequent shortening of the clinical efﬁcacy (Jalving et al 2006). For example, in a study of comparison with ranitidine, (Richter et al 2004) reports that pantoprazole provided the greatest degree and the most consistent effect for all efﬁcacy parameters compared with the ranitidine throughout the 12 months of evaluation (van Zyl et al 2004). Maintenance dosage is not well established. Patients with moderate to severe symptoms of esophagitis, whose disease has been initially controlled with PPIs, frequently, require PPI maintenance dosages similar to those used for initial esophageal healing (Donnellan et al 2005; Berardi 2006). A dissimilar result was found in a recent European trial (Escourrou et al 1999), which indicated that pantoprazole 20 mg/day was at least as effective as 40 mg/day with respect to prevent symptomatic and endoscopic recurrence in patients with grade B and C esophagitis who were initially healed with either pantoprazole (40 mg/day) or omeprazole (20 mg/day). Data on the safety of prolonged therapy with PPI and pantoprazole are relatively sparse. In early days there was particular concern about hypergastrinemia in response to profound acid inhibition with resultant endocrine cell hyperplasia and possible tumor formation. Endocrine cell hyperplasia has been looked for in Man but is rarely found in the few reported studies. The development of frank carcinoid tumors is described to be exceptional (Laine et al 2000; Bardhan et al 2005; Jalving et al 2006). There is inadequate evidence to support the association between PPIs and colonic polyps and no data has been reported on pantoprazole and an association with gastric or colorectal neoplasia in humans (Berardi 2006). Other concerns are about the possible bacterial overgrowth with consequent nitrosamine formation induced by the suppression of gastric acid in patients treated with PPIs. Helicobactor pylori and many other urease positive gastric bacteria can be advocated at this point (Brandi et al 2006). A causal relationship between intragastric nitrosamine and gastric development of neoplasia in patients taking PPIs has never been established (Freston 1997; Garnett 1998). The inﬂuence of H. pylori infection during prolonged PPIs therapy is still in doubt. Reductions in chronic antral gastritis and corresponding increases in chronic corpus gastritis in those with H. pylori infection have been observed; in contrast, there is little change in the uninfected. A corpus gland atrophy has been also observed and it develops in some Clinical Interventions in Aging 2007:2(1) 87