New guidelines for ‘deprescribing’ PPIs

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Proton pump inhibitors (PPIs) are a very commonly prescribed class of drugs for patients with acid peptic disorders. They have been generally regarded as safe and well tolerated. And, their long-term use is common.

However, recently, there have been concerns about the use of PPIs, especially long-term use. PPIs have been linked to increased risk of osteoporotic fractures, pneumonia, Clostridium difficile infection and rebound acid hypersecretion, especially in the older population. Long-term use may also affect patient compliance to the prescribed treatment.

Evidence-based recommendations published in the May 2017 issue of Canadian Family Physician to help the physician decide when and how to safely stop the PPIs or reduce their dose, called ‘deprescribing’ PPIs. This can be done in three ways:

• Reducing the dose by ‘intermittent’ use for a fixed duration; ‘on-demand’ use or using a lower ‘maintenance’ dose.
• Stopping the drug can be done by abruptly discontinuing the drug or via a tapering regime.
• Stepping down means abrupt discontinuation or PPI tapering followed by an histamine-2 receptor antagonist (H2RA)

These guidelines recommends deprescribing PPIs in adults who have completed a minimum of 4 weeks of PPI treatment for heartburn or mild to moderate gastroesophageal reflux disease (GERD) or esophagitis, and whose symptoms are resolved.

• Decrease the daily dose or stop and change to on-demand use. This has been given a strong recommendation.
• Or, an H2RA can be considered as an alternative to PPIs. This alternative has been given a weak recommendation due to the higher risk of symptoms recurring.

These recommendations are not applicable to patients who have severe esophagitis grade C or D, or a documented history of bleeding gastrointestinal ulcers or have Barrett esophagus.

(Source: Can Fam Physician. 2017 May;63(5):354-364)

Dr KK Aggarwal
National President IMA & HCFI