New Guidelines for Deprescribing Proton Pump Inhibitors

A new practice guideline aims to help clinicians make decisions about when and how to safely deprescribe proton pump inhibitors (PPIs). The evidence-based recommendations incorporate data from key clinical studies and focus on outcomes that are important to patients, including the harms and benefits of PPI dose reduction. Barbara Farrell, PharmD, ACPR, FCSHP, from the University of Ottawa in Ontario, Canada, and colleagues published the evidence-based guideline in the May issue of Canadian Family Physician. "A PPI deprescribing guideline works in conjunction with current treatment guidelines because it offers clinicians recommendations and clinical considerations to help them deprescribe PPIs in patients after an appropriate treatment duration or if long-term therapy is being reevaluated," the authors write. Concern about the overuse of PPIs has been rising as data accumulate regarding potential adverse effects, including increased risk for kidney disease, Clostridium difficile infection, and hip fractures. Chronic PPI use is also common, with some studies showing a lack of ongoing indication for PPI treatment in as many as 40% to 65% of hospitalized patients who receive the drugs. "When PPIs are inappropriately prescribed or used for too long, they can contribute to polypharmacy with its attendant risks of nonadherence, prescribing cascades, adverse reactions, medication errors, drug interactions, emergency department visits, and hospitalizations," the authors continue. Current guidelines for treating gastroesophageal reflux disease and peptic ulcer disease recommend a short course of PPIs and suggest clinicians should attempt to either discontinue these drugs or treat patients using the lowest effective dose. However, current guidelines provide no advice on how clinicians can deprescribe PPIs. Indeed, no comprehensive evidence-based recommendations have been available to help clinicians taper or discontinue PPIs, or guide them on intermittent use, step-down, or on-demand treatment strategies. According to Dr Farrell and colleagues, the new guideline is accompanied by a decision-support algorithm to address clinicians' common front-line questions about PPI deprescribing. It "provides practical recommendations for making decisions about when and how to reduce the dose of or stop PPIs," they note. During the guideline development process, review of the evidence failed to identify serious harms for PPI deprescribing in adults, the authors say. The new recommendations focus on adults older than 18 years with upper gastrointestinal symptoms who have received PPIs for a minimum of 4 weeks and have experienced symptom resolution. For these patients, the guidelines recommend clinicians should either reduce the daily dose of PPI or stop the drug and switch the patient to on-demand PPI use. The authors rate the recommendation to lower the dose of PPI or switch to on-demand use as "strong." As an alternative to using PPIs, the guidelines suggest clinicians may consider stepping down to histamine-2 receptor antagonist therapy. However, because of the greater risk for symptom return with this therapy, this recommendation is considered "weak." Although the evidence base used to develop the guideline predominantly relates to gastroesophageal reflux disease or esophagitis, the authors note that the data can be extrapolated to apply to patients with other upper gastrointestinal disorders, such as peptic ulcer disease, for which PPIs have more modest efficacy or which typically call for a short-term course of PPIs. Deprescribing is likely to be more effective in such cases, they say. Overall, the authors believe use of these new guidelines will encourage clinicians to carefully evaluate patients' continued use of PPIs, and potentially reduce polypharmacy. However, Dr Farrell and colleagues also emphasize that critical gaps in knowledge remain regarding PPI deprescribing. Future research "should address deprescribing for other PPI indications and in the frail elderly population, optimal tapering regimens or alternate treatments
to minimize symptom recurrence, consistent approaches to measuring outcomes, measurement of both positive and adverse drug withdrawal events, long-term harms and benefits, and costs," they conclude. Dr Farrell has reported receiving research funding to develop this guideline. She has reported receiving financial payments from the Institute for Healthcare Improvement and Commonwealth Fund for a deprescribing guidelines summary, and from the Ontario Long Term Care Physicians Association, the Ontario Pharmacists Association, and the Canadian Society of Hospital Pharmacists for speaking engagements. One coauthor holds a chair partially funded by AstraZeneca and has reported receiving financial payments from AstraZeneca for speaking engagements. The remaining authors have disclosed no relevant financial relationships. Can Fam Physician. 2017;63:354¬-364.