An Update from the American Gastroenterological Association
Deprescribing (the planned process of reducing a medication’s dose or stopping it completely) is now a relatively well-known term among hospice clinicians.1 Clear deprescribing guidance is lacking for many drugs, but this isn’t the case for proton pump inhibitors (PPIs). In addition to robust resources from Deprescribing.org and Primary Health Tasmania, the American Gastroenterological Association (AGA) recently published their deprescribing advice for PPIs.
PPI use is extremely common, with up to 40% of patients 70 years and older having used them.2,3 While they’re commonly used, evidence suggests that they’re overused. In fact, one study found that nearly two-thirds of patients had no clear indication for taking their PPI.2
PPIs have been linked to the development of chronic kidney disease, fractures, dementia, diarrhea, clostridium difficile infection, pneumonia, vitamin B-12 deficiency, and hypomagnesemia.1-3 Additionally, their overuse leads to increased pill burden, drug-drug interactions, and increased costs for hospices.1,2
According to the new guidance from the AGA, all patients taking a PPI should have a regular review of the indications for ongoing PPI use.2 The goals of these reviews are to assess the risks and benefits of ongoing use and to identify patients who might be candidates for deprescribing.2 The AGA’s recommendations are consistent with existing deprescribing guidelines, but one of the strengths of the AGA’s best practices is clarifying ideal candidates for ongoing therapy versus deprescribing.1,2,4 Generally speaking, it’s the AGA’s viewpoint that patients with conditions like severe erosive esophagitis, esophageal ulcer, peptic stricture, Barrett’s esophagus, eosinophilic esophagitis, idiopathic pulmonary fibrosis, and those at high risk for upper gastrointestinal bleeding should usually not be considered for PPI deprescribing.2 Patients without a definitive indication for chronic PPI use should be considered for a trial of deprescribing.2
Per the AGA’s recommended best practices, deprescribing via taper or abrupt discontinuation are both reasonable strategies.2 Deprescribing via taper has been proposed due to the concern of rebound acid hypersecretion, a possible complication of discontinuing chronic PPI therapy.2 One study compared abrupt discontinuation to an every other day taper over 3 weeks and found no significant difference in terms of the likelihood of remaining off of PPIs and symptom-free after 6 months.2 If symptoms recur after PPI discontinuation, proposed strategies to manage symptoms include resuming daily PPI use until symptoms resolve, using as needed histamine type-2 receptor antagonists (e.g., famotidine), or using as needed antacids (e.g., calcium carbonate).2 Symptoms that persist for more than two months after PPI discontinuation are suggestive of an indication for resuming and continuing PPI therapy.2 Below is a summary of the AGA’s guidance on deprescribing PPIs.
Summary of AGA Best Practice Advice Statements2
- Patients taking PPIs should have a regular review of the indications present for ongoing use and those indications should be documented.
- Consider a deprescribing trial for patients without a definitive indication for chronic PPI use.
- Most patients with an indication for ongoing PPI use who are taking them twice-daily should be considered for a reduction to once-daily dosing.
- Patients with a complicated GERD history (e.g., severe erosive esophagitis, esophageal ulcer, or peptic stricture) should generally not be considered for PPI deprescribing.
- Patients with conditions such as Barrett’s esophagus, eosinophilic esophagitis, or idiopathic pulmonary fibrosis should generally not be considered for PPI deprescribing.
- Before deprescribing PPIs, assess the risk for upper GI bleeding using an evidence-based strategy.
- Patients who are at high risk for upper GI bleeding should generally not be considered for PPI deprescribing.
- If stopping a patient’s PPI after long-term use, advise the patient that they may develop occasional upper GI symptoms caused by rebound acid hypersecretion.
- Deprescribing via taper or abrupt discontinuation can be considered.
- The decision to stop a PPI should only be based on the lack of an indication for its use and should not be based on the potential for adverse events associated with PPI use to occur.
John Corrigan, PharmD
Clinical Pharmacist, OnePoint Patient Care
John’s primary responsibilities as a clinical pharmacist at OnePoint Patient Care are staff and partner education, medication utilization reviews, and assisting with formulary development and maintenance. He attended the University of Iowa for both undergraduate studies and pharmacy school. He earned a PharmD from the University of Iowa College of Pharmacy in 2013. He was first introduced to hospice and OnePoint Patient Care as a 4th year pharmacy student, completing a 5-week elective clinical hospice pharmacy rotation. He started his employment with OnePoint Patient Care as a staff pharmacist in 2014. He transitioned to his current role, as a clinical pharmacist, in the spring of 2019.
- Farrell B, Pottie K, Thompson W, et al. Deprescribing proton pump inhibitors: Evidence-based clinical practice guideline. Can Fam Physician. 2017;63:354-364. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5429051/
- Targownik L, Fisher D, Saini S. AGA Clinical Practice Update on De-Prescribing of Proton Pump Inhibitors: Expert Review. Gastroenterology. 2022:1-9. doi:1053j.gastro.2021.12.247
- Hamza Z. AGA: Consider De-Prescribing PPIs in Patients With ‘Murky’ Indications. Medpage Today. February 22, 2022. Accessed February 23, 2022. https://www.medpagetoday.com/gastroenterology/gerd/97313?xid=nl_covidupdate_2022-02-23&eun=g1496867d0r&utm_source=Sailthru&utm_medium=email&utm_campaign=DailyUpdate_022322&utm_term=NL_Gen_Int_Daily_News_Update_active
- A Guide to Deprescribing Proton Pump Inhibitors. Primary Health Tasmania. Updated May 2019. Accessed March 29, 2022. https://www.primaryhealthtas.com.au/wp-content/uploads/2018/09/A-Guide-to-Deprescribing-Proton-Pump-Inhibitors-2019.pdf