Skip to content
Umbrella Aged Care
← Medicines and deprescribing

Stomach and bowel medicines

GPs & clinicians Aged care staff 7 min read

By Dr Josh Hatch, FRACGP

Proton pump inhibitors, such as pantoprazole and esomeprazole, are among the most common long-term medicines in residential care. In a New South Wales study of 6,439 residents, 54% received one, and more than four in five of those took it for longer than 12 weeks 33. Laxatives raise different questions. Both deserve a look at each review.

Numbers in the text link to the 6 sources listed at the foot of this page.

Proton pump inhibitors: how much is too much?

In the same study, after allowing for residents who needed stomach protection because they took medicines that raise bleeding risk, 27% of residents on a proton pump inhibitor had no such reason to continue beyond 12 weeks. At the same time, 39% of residents on long-term bleeding-risk medicines had no stomach protection 33. Overuse and underuse were both common.

A Canadian evidence-based guideline recommends trying to reduce the dose, stop, or change to on-demand use in adults who have taken a proton pump inhibitor for at least four weeks for heartburn or mild to moderate reflux or oesophagitis and whose symptoms have settled. It does not apply to people with Barrett’s oesophagus, severe oesophagitis or a history of bleeding ulcers 35.

The evidence

Stepping down a long-term proton pump inhibitor

Uncertain / conflicting

Moving to on-demand use cuts the number of tablets but brings reflux symptoms back for some people. Long-term benefit and harm are unknown.

The evidence

A Cochrane review of six trials with 1,758 participants, almost all outpatients in middle age with mild reflux, found that on-demand use increased the risk of poor symptom control compared with daily use (risk ratio 1.71, 95% CI 1.31 to 2.21; low-quality evidence) and reduced use by about four tablets a week (moderate-quality evidence). There were insufficient data on long-term benefits and harms 34.

In practice

None of these trials was in residential care 34. For a resident with no clear ongoing reason for the medicine, a trial of reduction with a plan for what to do if symptoms return is a reasonable option.

A daily fibre supplement to reduce laxative use

Promising, not yet proven

In one small trial, a fibre supplement reduced laxative use without changing bowel frequency.

The evidence

In a trial in four Hong Kong long-term care homes, 52 residents with chronic constipation were randomised to a daily fibre supplement (partially hydrolysed guar gum) or water for four weeks. Bowel frequency and stool form did not differ, but residents taking the fibre used fewer laxatives in the third and fourth weeks 37.

In practice

The trial was small, short and single-blinded 37.

Are long-term proton pump inhibitors harmful?

Observational studies have linked long-term use with Clostridioides difficile infection, pneumonia, low magnesium and fractures 34. The best test of these concerns is a placebo-controlled trial. In 17,598 people with stable cardiovascular disease randomised to pantoprazole 40 mg or placebo for a median of three years, there were no significant differences in pneumonia, fractures, chronic kidney disease, dementia or deaths. Enteric infections were slightly more common with pantoprazole (1.4% against 1.0%; odds ratio 1.33, 95% CI 1.01 to 1.75) 36.

The trial was not in frail older people, and two of its authors were affiliated with Bayer 36. Taken together, the usual reason to review a proton pump inhibitor in residential care is that it may no longer be needed, rather than fear of harm.

Laxatives

Bowel care matters a great deal to residents, but the trials of laxative and fibre regimens in residential care found for this page were small.

Laxatives also have a downside. Faecal incontinence is common in care homes, with a median prevalence of 43% across studies, and laxative use and loose stools were among the factors associated with it 38.

At review, for bowel medicines

  • What is the current bowel pattern?. A bowel chart kept over a week or two gives a better picture than memory.

  • Has anything changed?. A new or stopped opioid, a change in mobility or a change in eating can all change what is needed.

  • Are there loose stools or incontinence?. Laxative use and loose stools are both associated with faecal incontinence, so these may be a reason to look at the regimen again 38.

Sources cited on this page

  1. 33 Wabe N, Urwin R, Meulenbroeks I, et al. Over- and underuse of proton pump inhibitors in nursing homes: a multisite longitudinal cohort study. J Am Med Dir Assoc. 2025;26(2):105393. (6,439 residents, 34 New South Wales homes; observational.) View source
  2. 34 Boghossian TA, Rashid FJ, Thompson W, et al. Deprescribing versus continuation of chronic proton pump inhibitor use in adults. Cochrane Database Syst Rev. 2017;3:CD011969. (6 trials, 1,758 outpatients.) View source
  3. 35 Farrell B, Pottie K, Thompson W, et al. Deprescribing proton pump inhibitors: evidence-based clinical practice guideline. Can Fam Physician. 2017;63(5):354–64. (No DOI; PubMed record linked.) View source
  4. 36 Moayyedi P, Eikelboom JW, Bosch J, et al. Safety of proton pump inhibitors based on a large, multi-year, randomized trial of patients receiving rivaroxaban or aspirin. Gastroenterology. 2019;157(3):682–91.e2. (17,598 people with stable cardiovascular disease; two authors affiliated with Bayer.) View source
  5. 37 Chan TC, Yu VMW, Luk JKH, Chu LW, Yuen JKY, Chan FHW. Effectiveness of partially hydrolyzed guar gum in reducing constipation in long term care facility residents: a randomized single-blinded placebo-controlled trial. J Nutr Health Aging. 2022;26(3):247–51. (52 residents, Hong Kong.) View source
  6. 38 Musa MK, Saga S, Blekken LE, Harris R, Goodman C, Norton C. The prevalence, incidence, and correlates of fecal incontinence among older people residing in care homes: a systematic review. J Am Med Dir Assoc. 2019;20(8):956–62.e8. (23 observational studies.) View source

See every source cited across the medicines and deprescribing section →

Written by Dr Josh Hatch, FRACGP. General information only, reflecting his reading of the published evidence as at October 2026. It is not individual medical advice, does not create a doctor–patient relationship, and must not be used to start, stop or change any treatment. Evidence and Australian regulatory, PBS and program arrangements change — always confirm current advice with the treating GP, pharmacist or specialist.

This is general education, not a clinical protocol. The doctors who practise with Umbrella Aged Care are independent general practitioners, and each makes their own clinical decisions with the resident and family. Your GP’s advice for an individual may differ from what is written here. If it does, please ask them to talk it through with you.

Enquire about care