Deprescribing PPIs: An Algorithm

Linda Brookes, MSc


July 06, 2017

This series on deprescribing focuses on the decision-support tools developed for healthcare professionals by Dr Barbara Farrell, PharmD, and colleagues in Ottawa, Canada. The first in a series of drug class-specific algorithms and guidelines issued by Dr Farrell's group is focused on proton pump inhibitors (PPIs). Dr Farrell, a clinical scientist at the Bruyère Research Institute and the C.T. Lamont Primary Health Care Research Centre, and assistant professor at the Department of Family Medicine, University of Ottawa, told Medscape why the guideline was needed and how it can be used.

Since the first PPI received regulatory approval in the late 1980s, six PPIs (omeprazole, esomeprazole, lansoprazole, dexlansoprazole, pantoprazole, and rabeprazole) have become available in the United States and Canada. PPIs have become one of the most commonly prescribed therapeutic drug classes.[1,2] For Dr Farrell, who regularly conducts medication reviews with patients in a geriatric hospital, "It's as though almost every patient who comes through your door is on a PPI. People take them like water," she says.

Inappropriate Prescribing

Despite such frequent use, however "about half the people who are on a PPI don't have a documented reason anywhere in their chart," Dr Farrell notes. Studies have shown that between 40% and 65% of prescriptions for a PPI do not have an appropriate indication (ie, acute ulcers, gastroesophageal reflux disease [GERD], erosive esophagitis, hypersecretory conditions, prevention of nonsteroidal anti-inflammatory drug-induced ulcers, or treatment of Helicobacter pylori infections).[3] "This is costing the healthcare plans—whether public or private—a lot of money," Dr Farrell stresses. Public drug program spending on PPIs in Canada is increasing, and in 2015 reached Can$253.3 million—2.9% of the total expenditure.[4]

Chronic use of PPIs is also increasing, even though most indications for PPIs require treatment for only 4-8 weeks, probably because PPIs have been perceived as safe and well-tolerated, Dr Farrell suggests. However, in observational studies, long-term PPI use has been associated with uncommon but serious adverse effects, including hip fracture, community-acquired pneumonia, Clostridium difficile infection, kidney disease, hypocalcemia, and hypomagnesemia.[5,6,7,8]

Increasing evidence for increased risks with long-term PPI use has led to changes in guidance and recommendations. In 2015, the American Geriatrics Society added PPIs to its updated version of the Beers Criteria (lists of potentially inappropriate medications for older adults), with a recommendation to avoid the use of PPIs for > 8 weeks in patients not at high risk for gastrointestinal disease.[9] In 2017, the American Gastroenterological Association issued a clinical practice update recommending that most patients with uncomplicated GERD have their PPI dosage reduced from twice to once daily.[8] However, real-world guidelines and decision-support aids for deprescribing have been lacking, Dr Farrell notes.


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