PPI Deprescribing: Guidelines on When and How to Safely Stop Medications

Recently-published guidelines offer evidence-based recommendations for health care professionals on safely tapering or stopping proton pump inhibitors (PPIs) in patients.¹

The guidelines used a systematic review of PPI deprescribing trials and analyses of the effects of prolonged PPI use. A team of 5 health care professionals including 1 family physician, 3 pharmacists, and 1 gastroenterologist collaborated to provide input on clinical considerations and evidence-based practice recommendations.

Based on a systematic review, the researchers determined that PPIs can be safely deprescribed in many patients taking them for common indications of GERD and mild esophagitis.

Pharmacist inclusion within interdisciplinary teams is noted as an effective approach to help with PPI deprescribing. Pharmacist involvement can reduce unnecessary use of PPIs and facilitate patient education, dose changes, monitoring, and alerting the prescriber to ongoing symptoms.

These recommendations do not apply to patients who have or have had Barrett esophagus, severe esophagitis grade C or D, or documented history of bleeding gastrointestinal ulcers. The researchers used the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) system for guideline development.

For adults who are older than 18 years old with upper GI symptoms, who have completed a 4-week course of PPI treatment, resulting in symptom resolution, the researchers recommended:

• Decreasing the daily dose or stopping and changing to on-demand use (strong recommendation, low quality evidence).
• Considering an H₂RA as an alternative to PPIs (weak recommendation, moderate-quality evidence).

Important questions to consider when making decisions about deprescribing PPIs include:

• Are there indications or risk factors that warrant continued use?
• How should tapering be approved?
• What monitoring needs to be done and how often, and how should symptoms be managed?
• What other approaches help with PPI deprescribing?

The guideline is accompanied by an algorithm that outlines the recommendations’ rationale.

According to the researchers, current PPI guidelines for patients with GERD and peptic ulcer disease support a short duration of treatment and suggest discontinuing PPIs in most patients or maintaining therapy at the lowest effective dose.

The researchers concluded that these guidelines are the first in a series of recommendations designed to help health care professionals decide when and how to safely stop medications.

Reference

• Farrell B, Pottie K, Thompson W, et al. Deprescribing proton pump inhibitors. Canadian Family Physician. 2017; 63(5):354-364. http://www.cfp.ca/content/63/5/354.long