#190 Proton Pump Inhibitors (PPIs): Is Perpetual Prescribing Inevitable?
CLINICAL QUESTION
How successful are attempts to stop PPIs and how can clinicians improve chances of success?
BOTTOM LINE
Using a range of deprescribing strategies, about 25% of patients with gastroesophageal reflux disease (GERD) or dyspepsia can stop PPI use and another 30-50% can decrease their dose. Older patients and those who taper appear more successful in stopping PPIs.
Reading Tools for Practice Article can earn you MainPro+ Credits
Join NowAlready a CFPCLearn Member? Log in
EVIDENCE
- Clustered randomized controlled trials:
- Patients (n=196) taking twice daily PPIs for >8 weeks were randomized to receive information pamphlets with academic detailing for their physician versus standard care.1 At six months:
- 30% stopped PPI or changed to Histamine Receptor Antagonists (H2RA) versus 19% in control group, Number Needed to Treat (NNT)=10.
- Additional 50% reduced PPI dose.
- 113 dyspeptic patients randomized to receive a letter encouraging stopping/decreasing PPIs or usual care.2 At 20 weeks:
- 13% off PPI, compared to 5% in control group (NNT=13).
- Additional 9% reduced their dose.
- Patients (n=196) taking twice daily PPIs for >8 weeks were randomized to receive information pamphlets with academic detailing for their physician versus standard care.1 At six months:
- Cohort studies of patients on PPIs for >8 weeks:
- 73 Veterans with GERD attempted taper then stopping PPI.3 At one year:
- 34% switched to H2RA, 15% off all acid reducers.
- Older patients appeared more successful in stopping.
- 166 dyspeptic/GERD patients offered H. Pylori testing and treatment, then educated about symptoms, lifestyle and PPIs.4 At one year:
- 34% stopped, additional 50% reduced their dose.
- 27 GERD patients reviewed PPI use at periodic health exam.5 At 10 weeks:
- Ten (37%) stopped PPI: Six completely, four changed to H2RA.
- Of 97 predominantly GERD patients with normal gastroscopy, 27% stopped PPIs at one year.6
- 73 Veterans with GERD attempted taper then stopping PPI.3 At one year:
- ~60% long-term PPI users may not need them.7
- PPI use associated with (but causation unclear):
- Clostridium difficile colitis:
- Community dwelling without antibiotics (1/10,000 risk)8 to in-hospital on antibiotics and PPIs (8-10% risk).9
- Fractures: Extra one in 2000 women over eight years.10
- Pneumonia.11
- Vitamin B12 and magnesium deficiencies.12,13
- Clostridium difficile colitis:
- Abruptly stopping PPIs may cause transient rebound GERD or dyspepsia symptoms.14,15
- Tapering may help.6
- Long-term PPIs should be considered for patients with recurrent symptoms, endoscopic esophagitis, complications from GERD (example: stricture), or those requiring gastroprotection.
Latest Tools for Practice
#404 From Nerve Pain to Knee Pain: Gabapentinoids for osteoarthritis
Are gabapentinoids effective for the treatment of osteoarthritis?
#403 A Whiff of Prevention: Treating Male Partners to Reduce Bacterial Vaginosis Recurrence
Does treating male sexual partners of females undergoing treatment for bacterial vaginosis infection decrease recurrence?
#402 Nipple Confusion or Nonsense? Pacifiers and Breastfeeding Duration
In term infants, does restricting early use of pacifiers result in higher rates of breastfeeding up to 6 months of age?
Information seems more principle than practical. I.e. it has no information about how to actually get patients to taper PPI’s.
Information seems more principle than practical. That is there is no information about how to get patients to taper PPI’s.