Deprescribing Proton Pump Inhibitors

Deprescribing Proton Pump Inhibitors
Jamie Erickson, Pharm.D., Cash Wise Clinic Pharmacy/Carris Health

Background: Proton pump inhibitors (PPIs) are a widely used medication class for the treatment of many GI disorders. An article from Lee and McDonald stated that the United States spent roughly $79 billion on PPIs from 2007 to 2011. Although PPIs are effective inhibitors of gastric acid secretion, they may also cause adverse effects and health risks. Some of the most common adverse effects associated with PPIs include headache, nausea, diarrhea, and rash. However, they are also associated with more serious health implications including higher risk of fractures, C. difficile infection, community-acquired pneumonia, vitamin B-12 deficiency, and hypomagnesemia. A recent systematic review and meta-analysis published by Willems et al. explored the association between the use of acid suppressants and the risk of colonization with multidrug-resistant microorganisms (MDROs). This study reviewed 17 observational studies and found that patients treated with PPIs had increased odds of MDRO colonization by approximately 81% (1.81 [95% CI 1.52-2.16]). Studies cited in Canadian clinical practice guidelines for deprescribing PPIs consistently estimate that inappropriate use of PPIs occurs in 40% to 65% of patients to whom they are prescribed. This demonstrates the importance of routine reassessment of indication for PPI use and consideration of deprescribing, which Thompson and Farrell define as “the process of tapering, stopping, discontinuing, or withdrawing drugs, with the goal of managing polypharmacy and improving outcomes.” 

Evidence and Discussion: To date, there are few guidelines for deprescribing PPIs; however, a publication in the Canadian Family Physician systematically reviewed the evidence for deprescribing PPIs and developed a decision-support algorithm to help guide clinicians in the deprescribing process. The algorithm is targeted toward adults over the age of 18 who have been taking a PPI for at least four weeks with symptom resolution for treatment of upper GI symptoms including esophagitis, gastroesophageal reflux disease (GERD), peptic ulcer disease (PUD), and stress ulcer prophylaxis. The algorithm should not be used for those with Barrett’s esophagus, severe esophagitis grade C or D, or history of bleeding GI ulcers as a gastroenterologist should be consulted if deprescribing PPIs is considered in these patients. The algorithm provides equally strong recommendations to either lower the current PPI dose or switch from continuous to on-demand use of PPIs, which is defined as discontinuing the medication after symptom resolution and waiting until symptoms recur, at which point the medication is taken daily again until symptoms resolve. The current evidence suggests a minimal risk of returning symptoms with the above deprescribing practices. Patients should be monitored at four weeks post-deprescribing to assess symptom control and again at 12 weeks to assess symptom control and need for on-demand treatment or return to continuous treatment. The algorithm places a weak recommendation on step-down to H2-receptor antagonists due to higher risk of symptom return. In addition, they discuss that the use of nonpharmacologic interventions and OTC antacids can be beneficial to manage occasional breakthrough symptoms. This algorithm and other deprescribing resources are readily available at deprescribing.org. 

Clinical Impact: Although there is insufficient evidence from randomized clinical trials that one tapering approach is better than another, the above guidance can be used by clinicians as a tool along with consideration of what is most convenient and acceptable to the patient when deprescribing PPIs. Patients and caregivers may be more likely to trial deprescribing of PPIs if they understand the rationale for doing so including risks of continued or long-term PPI use. Inclusion of pharmacists as a part of the patient care team may be beneficial to help facilitate patient education, dose changes, and monitoring for symptom recurrence. 

References:

  1. Lee TC, McDonald EG. Deprescribing Proton Pump Inhibitors, Overcoming Resistance. JAMA Intern Med. 2020;180(4):571-573. doi:10.1001/jamainternmed.2020.0040

  2. Willems RP, Van Dijk K, Ket JC, et al. Evolution of the Association Between Gastric Acid Suppression and Risk of Intestinal Colonization With Multidrug-Resistant Microorganisms. JAMA Intern Med. 2020;180(4):561-571. doi:10.1001/jamainternmed.2020.0009

  3. Farrell B, Pottie K, Thompson W, et al. Deprescribing Proton Pump Inhibitors: Evidence-based Clinical Practice Guideline. Canadian Family Physician. 63(5):354-364. 

  4. Thompson W, Farrell B. Deprescribing: What Is It And What Does The Evidence Tell Us? Can J Hosp Pharm. 2013;66(3):201-202.