AGA Clinical Practice Update on De-Prescribing of Proton Pump Inhibitors: Best Practice Advice
Proton pump inhibitors (PPIs) are among the most commonly used medications in the world. Developed for the treatment and prevention of acid-mediated upper gastrointestinal conditions, these agents are being used increasingly for indications where their benefits are less certain.
PPI over prescription imposes an economic cost and contributes to poly pharmacy. In addition, PPI use has been increasingly linked to a number of adverse events (PPI-associated adverse events [PAAEs]). Therefore, de-prescribing of PPIs is an important strategy to lower pill burden while reducing real costs and theoretical risks.
The purpose of this clinical update was to provide Best Practice Advice (BPA) statements about how to approach PPI de-prescribing in ambulatory patients.
TAKE-HOME MESSAGE
Prescribers are responsible for determining whether PPI use is absolutely or conditionally indicated and, when uncertainty exists, to incorporate patient perspectives into PPI decision making.
Clinical providers should regularly review the indications for PPI use in patients, and de-prescribing should be considered in patients without an indication for chronic PPI use.
Physicians should not use concern about unproven complications of PPI use as a justification for PPI de-prescribing if there remain ongoing valid indications for PPI use.
Indications for remaining on PPIs are complicated GERD (severe erosive esophagitis, reflux-mediated stenosis), barrett’s esophagus, eosinophilic esophagitis, idiopathic pulmonary fibrosis, Zollinger-Ellison syndrome and those at high risk for upper GI bleeding.
Find out the Best Practice Advice Statements below….
Doctors Liked to Read More
This clinical practice update document from the American Gastroenterological Association (AGA) presents best practice advice statements about approaching de-prescribing of PPIs in outpatient clinical practice.
Best Practice Advice 1
All patients taking a PPI should have a regular review of the ongoing indications for use and documentation of that indication. This review should be the responsibility of the patient’s primary care provider.
Best Practice Advice 2
All patients without a definitive indication for chronic PPI should be considered for trial of de-prescribing.
Best Practice Advice 3
Most patients with an indication for chronic PPI use who take twice-daily dosing should be considered for step down to once-daily PPI.
Best Practice Advice 4
Patients with complicated gastroesophageal reflux disease, such as those with a history of severe erosive esophagitis, esophageal ulcer, or peptic stricture, should generally not be considered for PPI discontinuation.
Best Practice Advice 5
Patients with known Barrett’s esophagus, eosinophilic esophagitis, or idiopathic pulmonary fibrosis should generally not be considered for a trial of de-prescribing.
Best Practice Advice 6
PPI users should be assessed for upper gastrointestinal bleeding risk using an evidence-based strategy before de-prescribing.
Best Practice Advice 7
Patients at high risk for upper gastrointestinal bleeding should not be considered for PPI de-prescribing.
Best Practice Advice 8
Patients who discontinue long-term PPI therapy should be advised that they may develop transient upper gastrointestinal symptoms due to rebound acid hypersecretion.
Best Practice Advice 9
When de-prescribing PPIs, either dose tapering or abrupt discontinuation can be considered.
Best Practice Advice 10
The decision to discontinue PPIs should be based solely on the lack of an indication for PPI use, and not because of concern for PAAEs. The presence of a PAAE or a history of a PAAE in a current PPI user is not an independent indication for PPI withdrawal. Similarly, the presence of underlying risk factors for the development of an adverse event associated with PPI use should also not be an independent indication for PPI withdrawal.
Abbreviations used in this paper:
BPA (Best Practice Advice), GERD (gastroesophageal reflux disease), GI (gastrointestinal), PAAE (proton pump inhibitor–associated adverse event), PCP (primary care provider), PPI (proton pump inhibitor), RAHS (rebound acid hypersecretion), RCT (randomized controlled trial)
Much of the increasing concern about PPI overuse and the need for de-prescribing has been driven by concern about PPI-associated adverse events (PAAEs), including some associated with significant morbidity or mortality.
Many of these associations between PPI use and PAAEs lack a plausible mechanism of action. Moreover, no RCT has yet demonstrated that PPI users have an increased incidence of any of the PAAEs.
If patient does require long-term PPI therapy, be aware of nutrient deficiencies from a lack of acid needed for absorption. Consider checking levels of vitamin B12, iron, calcium, magnesium, folic acid, and zinc.
Comments
You must login to write comment