Deprescribing PPIs: Do I still need the acid-reducing pill?

Contributed by: Dr Vivian Ewa, MBBS, CCFP (CoE), PG DipMedEd, FCFP, FRCP Edin. - View bio

Case

Mrs. Jones, an 86-year-old patient of yours, recently learned one of her medications is an acid-reducing pill. Currently, she takes several medications and wants the acid pill reviewed. She has a history of COPD, hypertension, type 2 diabetes mellitus and osteoarthritis of the knees. Her medication list includes: Tylenol, Ramipril, Vitamin D, oral Vitamin B12, Pantoloc, hydrochlorothiazide, Ventolin and a Spiriva inhaler.

Background

In Canada, about one in four seniors aged 65 years and above have three or more chronic medical disorders and are on six or more medications (1). Proton pump inhibitors (PPIs) are commonly prescribed and in a recent report of prescription drug use in Canada, Pantoloc was the fifth most commonly prescribed drug, with more than 11 million prescriptions in 2012 (2). PPIs are indicated for short-term treatment of mild GERD or esophagitis. Treatment is usually four to eight weeks duration (3, 4). In cases of moderate esophagitis with endoscopic evidence of Barrett’s esophagus and severe esophagitis grade C or D, long-term to lifelong treatment is indicated (5). Short-term PPI use for treatment of peptic ulcer disease is recommended for two to 12 weeks, unless maintenance therapy is clearly indicated, such as ongoing NSAID use (6). In cases of post-GI bleed associated with H. Pylori infections, anti-secretory therapy can be discontinued following eradication of the infectious bacteria except in cases where NSAID use is ongoing (6).

Evidence

Studies have shown that even when started for heartburn, mild GERD symptoms or esophagitis, PPIs are not reviewed and patients stay on them for years with no valid indication (7). Long-term use of PPIs is not without risks, including vitamin B12 deficiency (8, 9), osteoporosis (9, 10), pneumonia (11) and C. difficile associated diarrhea (12, 13).

Management

Deprescribing PPIs can be a challenge when information is lacking on the original indication for use. A thorough assessment that includes prior history of GERD symptoms, GI bleed and endoscopy can help tease out the indication for use. The website deprescribing.org (14) has a helpful algorithm to guide decision making when deprescribing PPIs (15). Where no indication exists, options include stopping PPIs and starting an H2RA versus gradually weaning off the PPI over a couple of weeks with the option for on demand use if symptoms recur (15). If the decision is made to deprescribe, the key to success is monitoring for rebound hyperacidity (7). Regular follow-up over the following four to 12 weeks is critical to assess for and manage adverse symptoms to deprescribing PPIs.

Back to the case

Mrs. Jones has been on Pantoloc 40 mg orally twice a day for the last five years. She is also on vitamin B12 1000 mcg orally daily. You suspect the reason for her low b12 is prolonged use of PPI. A review of her history and records does not reveal any history of GERD symptoms. There is no prior history of GI bleed or endoscopy. She is not taking any over-the-counter NSAIDs. Using the guidelines and algorithm for deprescribing PPIs on deprescribing.org (14), you reduce her Pantoloc to 40 mg once daily and follow up in four weeks. She tolerates this reduction with no symptoms of rebound hyperacidity. Pantoloc is stopped and you ask her to use 40 mg orally daily on demand for symptoms of heartburn, regurgitation or dyspepsia. Follow up after an additional four weeks shows on demand use five times in the last four weeks. The last use was about two weeks ago. She continues on demand use for another four weeks and this time does not use any PPI.

Conclusion

Long-term use of PPIs is not without risks. They should be reassessed and deprescribed when no longer indicated to reduce risk of adverse effects and pill burden.

References

1. Canadian Institute for Health Information. Seniors and the Health Care System: What is the Impact of Multiple Chronic Conditions? Ottawa; 2011.
2. Canadian Healthcare Network of Pharmacists 2013 Available from: www.canadianhealthcarenetwork.ca/pharmacists/magazines/pharmacy-practice/february-2013
3. Katz PO GL, Vela MF Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterology. 2013;108(3):308-28.
4. Jacobson BC FT, Shea TL, Mahlis EM, Lee TH, Wang TC. . Who is using chronic acid suppression therapy and why? American Journal of Gastroenterology. 2003;98(1):51-8.
5. Shaheen NJ, Gary WF, Prasad GI, Gerson LB. ACG Clinical Guideline: Diagnosis and Management of Barrett’s Esophagus. The American Journal of Gastroenterology. 2015;111(1):30.
6. Chey WD, Leontiadis GI, Howden CW, Moss SF. ACG Clinical Guideline: Treatment of Helicobacter pylori Infection. The American Journal Of Gastroenterology. 2017;112:212.
7. Heidelbaugh JJ, Kim A, H. , Chang R, Walker P, C. . Overutilization of proton-pump inhibitors: what the clinician needs to know. Therapeutic Advances in Gastroenterology. 2012;5(4):219-32.
8. Lam JR, Schneider JL, Zhao W, Corley DA. Proton pump inhibitor and histamine 2 receptor antagonist use and vitamin B12 deficiency. Jama. 2013;310(22):2435-42.
9. Sheen E, Triadafilopoulos G. Adverse effects of long-term proton pump inhibitor therapy. Digestive diseases and sciences. 2011;56(4):931-50.
10. Kwok CS, Yeong JK, Loke YK. Meta-analysis: risk of fractures with acid-suppressing medication. Bone. 2011;48(4):768-76.
11. Fohl AL, Regal RE. Proton pump inhibitor-associated pneumonia: Not a breath of fresh air after all? World journal of gastrointestinal pharmacology and therapeutics. 2011;2(3):17-26.
12. Loo VG, Bourgault AM, Poirier L, Lamothe F, Michaud S, Turgeon N, et al. Host and pathogen factors for Clostridium difficile infection and colonization. The New England journal of medicine. 2011;365(18):1693-703.
13. Pilotto A, Franceschi M, Vitale D, Zaninelli A, Di Mario F, Seripa D, et al. The prevalence of diarrhea and its association with drug use in elderly outpatients: a multicenter study. Am J Gastroenterol. 2008;103(11):2816-23.
14. Evidence-based deprescribing algorithm for proton pump inhibitors OPEN: the Ontario Pharmacy Evidence Network 2017 [Available from: www.open-pharmacy-research.ca/evidence-based-ppi-deprescribing-algorithm/].
15. Farrell B, Pottie K, Thompson W, Boghossian T, Pizzola L, Rashid FJ, et al. Deprescribing proton pump inhibitors. Evidence-based clinical practice guideline. 2017;63(5):354-64.