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#190 Proton Pump Inhibitors (PPIs): Is Perpetual Prescribing Inevitable?


CLINICAL QUESTION
QUESTION CLINIQUE
How successful are attempts to stop PPIs and how can clinicians improve chances of success?


BOTTOM LINE
RÉSULTAT FINAL
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 doseOlder patients and those who taper appear more successful in stopping PPIs. 



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EVIDENCE
DONNÉES PROBANTES
  • Clustered randomized controlled trials: 
    • Patients (n=196taking 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 groupNumber 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. 
  • 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 treatmentthen educated about symptoms, lifestyle and PPIs.4 At one year: 
      • 34% stoppedadditional 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
Context:    
  • ~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   
  • 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. 
 


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Author(s)
Auteur(s)
  • Michael R Kolber BSc MD CCFP MSc
  • Tony Nickonchuk BSc Pharm

1. Clyne B, Smith SM, Hughes CM, et al. Ann Fam Med. 2015; 13:545-53.

2. Krol N, Wensing M, Haaijer-Ruskamp F, et al. Aliment Pharmacol Ther. 2004; 19:917-22.

3. Inadomi IM, Jamal R, Murata GH, et al. Gastroenterol. 2001; 121:1095-1100.

4. Murie J, Allen J, Simmonds R, et al. Qual Prim Care. 2012; 20:141-8.

5. Walsh K, Kwan D, Marr P, et al. J Prim Health Care. 2016; 8(2):164-71.

6. Bjornsson E, Abrahamsson H, Simren M. Aliment Pharmacol Ther. 2006; 24:945-54

7. Forgacs I, Loganayagam A. BMJ. 2008; 336:2-3.

8. Kwok CS, Arthur AK, Anibueze CI, et al. Am J Gastroenterol. 2012; 107:1011-9.

9. Kuntz JL, Chrischilles EA, Pendergast JF, et al. BMC Infectious Diseases. 2011; 11:194

10. Khalili H, Huang ES, Jacobson BC, et al. BMJ. 2012; 344:e372.

11. Eom C-S, Jeon CY, Lim J-W, et al. CMAJ. 2011; 183(3):310-9.

12. Lam JR, Schneider JL, Zhao W, et al. JAMA. 2013; 310(22):2435-42.

13. Hess MW, Hoenderop JGJ, Bindels RJM, et al. Aliment Pharm Ther. 2012; 36:405-13.

14. Reimer C, Sondergaard B, Hilsted L, et al. Gastroenterol. 2009; 137:80-7.

15. Niklasson A, Lindström L, Simrén M, et al. Am J Gastroenterol. 2010; 105:1531-7.

Authors do not have any conflicts of interest to declare.