Proton Pump Inhibitors Without Definitive Indication Should be Deprescribed

Clinicians should consider deprescribing proton pump inhibitors (PPIs) in patients without a definitive indication for their use, according to expert guidance published online ahead of print in Gastroenterology.

“PPIs are among the most commonly used medications in the world,” wrote lead author Laura E. Targownik, MD, of Mount Sinai Hospital and the Temerty Faculty of Medicine at the University of Toronto, and coauthors. “Developed for the treatment and prevention of acid-mediated upper gastrointestinal conditions, these agents are being used increasingly for indications where their benefits are less certain.”

Pointing to the increased costs, polypharmacy, and theoretical risks that accompany unnecessary prescribing of PPIs, the authors developed updated guidance for deprescribing in certain patients.

Although patients lacking a definitive indication for PPI use are candidates for deprescribing, patients with complicated gastroesophageal reflux disease, Barrett’s esophagus, eosinophilic esophagitis, or idiopathic pulmonary fibrosis tend not to be, according to the advice. Patients with an indication for chronic PPI use who take twice-daily dosing are potential candidates for step down to once-daily dosing.

Assessment for upper gastrointestinal bleeding risk should occur before PPI deprescribing, and those deemed at high risk should not be considered for deprescribing.

Deprescribing can consist of either dose tapering or abrupt discontinuation, the authors explained. Patients who have taken PPIs for a long time should be advised that transient upper gastrointestinal symptoms from rebound acid hypersecretion can occur.

“The decision to discontinue PPIs should be based solely on the lack of an indication for PPI use, and not because of concern for PPI-associated adverse events,” the authors wrote. “The presence of a PPI-associated adverse event or a history of a PPI-associated adverse event in a current PPI user is not an independent indication for PPI withdrawal.”

—Jolynn Tumolo

Reference:
Targownik LE, Fisher DA, Saini SD. AGA clinical practice update on de-prescribing of proton pump inhibitors: expert review. Gastroenterology. Published online ahead of print, February 16, 2022.