Deprescribing PPIs: An Algorithm

Linda Brookes, MSc

Disclosures

July 06, 2017

New Deprescribing Guidelines

An algorithm[10] and information pamphlet[11] for deprescribing PPIs were issued by Dr Farrell's group in 2015, and the accompanying evidence-based guideline for healthcare providers was published in May 2017.[4,12] All relate mainly to adults (age >18 years) who have been taking a PPI continuously for ≥ 4 weeks for the treatment of GERD or mild to moderate esophagitis. Deprescribing may also be considered in patients who have completed short-term treatment with a PPI for stress ulcer prophylaxis, peptic ulcer disease, or Helicobacter pylori eradication.

Once the original indication for the PPI has been confirmed, the first recommendation is to reduce the dose. "This is a strong recommendation, based on evidence suggesting that there is no increased risk for returning symptoms compared with continuing the higher dose," Dr Farrell stressed. The second recommendation is to stop the PPI and have the patient use it on demand. "The situations in which you could probably completely stop the PPI would be when a patient leaves the intensive care unit (ICU) after having taken a PPI for ICU stress ulcer prophylaxis, or if they have completed treatment for H pylori; if they have occasional heartburn, they can just use it when they experience the heartburn," Dr Farrell explained.

Because some evidence suggests that abrupt discontinuation increases the risk for symptom relapse, gradual dose reduction is recommended. The guideline suggests following up with patients at 4 and 12 weeks after deprescribing to assess symptoms and on-demand PPI use and to assess whether other, nondrug approaches or switching to a histamine H2-receptor antagonist would be beneficial.

The algorithm and guideline have been incorporated into a toolkit for deprescribing in primary care issued by the Choosing Wisely Canada campaign.[13] The toolkit utilizes electronic health record messaging reminders to primary care providers, which has been shown to reduce the number of patients prescribed PPIs[14] as well as dose and cost.[15]

Importance of Communication

The guideline stresses the need to discuss the rationale for deprescribing with patients, because many patients may not be familiar or comfortable with the concept of reducing or stopping medications. Dr Farrell and her colleagues have also produced patient educational materials, including an infographic[16] and a brochure,[17] explaining why it might be important to stop a PPI and providing a stepwise tapering protocol. A PPI-deprescribing patient decision aid is in development to provide patients with information about the benefits and harms of different options and help them decide whether they want to follow deprescribing recommendations.[18] A pilot study is being carried out by Dr Farrell's group to evaluate the effects of a consult patient decision aid and the of role of pharmacists in delivering it to patients.[19]

Dr Farrell acknowledges that prescribers' lack of knowledge and a lack of resources can be barriers to deprescribing.[20] "I think there is some misinterpretation that when we say 'deprescribing,' we mean 'completely stop the medication,'" she suggests. "But deprescribing is a variety of options. It could mean reducing the dose, using the drug only when you need it, or switching to a safer alternative. It's important to communicate that, because if people believe that PPI deprescribing means always stopping the drug, then we are going to see people having gastrointestinal bleeding because they should have been taking it," she cautions. Nonetheless, she is optimistic about deprescribing interventions for PPIs. "This guideline has been very popular," she notes.

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