Inappropriate use and overuse of PPIs: A strategy for discontinuation

Abstract

Proton pump inhibitors (PPIs) have risks associated with long-term use, yet they are used chronically by more than 20 million Americans and account for more than $10 billion in health care spending.1https://apha.us/IMSInstituteGoogle Scholar Data on the effects of long-term PPI use are still emerging, but potential consequences include increased risk of vitamin and mineral deficiencies, bone fractures, changes in gut microbiota, Clostridium difficile–associated diarrhea, pneumonia, dementia, chronic kidney disease, gastric atrophy (higher risk among those with Helicobacter pylori infections), and gastric cancer. Overprescribing PPIs is common, with as many as 68.8% of patients being prescribed a PPI inappropriately at hospital discharge2J Manag Care Pharm. 2010; 16: 122-129PubMed Google Scholar and 36% to 39% of ambulatory patients lacking an indication for PPI use.3Am J Manag Care. 2010; 16: e228-e234PubMed Google Scholar, 4Am J Gastroenterol. 2003; 98: 51-58Crossref PubMed Scopus (113) Google Scholar As pharmacists, we can make an impact on inappropriate use and overuse of PPIs. At Central Pharmacy in Durham, NC, we initiated a service as part of a residency project to tackle the issue of PPI overuse. Our approach is to taper the PPI gradually while increasing the duration between each step to improve successful PPI discontinuation. The taper involves use of compounded omeprazole capsules, which allows the patient to decrease their PPI dose by 5 mg every 2 weeks. This regimen is also accompanied by lifestyle changes and supplements to support digestion and gastrointestinal (GI) health. Abrupt withdrawal of PPIs results in successful discontinuation in only 14% to 27% of patients who have used these medications for 8 weeks.5Eur J Gastroenterol Hepatol. 2010; 22: 1182-1188Crossref PubMed Scopus (26) Google Scholar, 6Int J Family Med. 2015; 2015: 175436Crossref PubMed Google Scholar Our goal is to have a higher success rate by tapering more gradually. Patients on step-down therapy with omeprazole 20 mg daily for 1 week, omeprazole 10 mg for 1 week, and omeprazole 10 mg every other day for 1 week saw slightly higher success rates, with 31% achieving discontinuation.7Aliment Pharmacol Ther. 2006; 24: 945-954Crossref PubMed Scopus (117) Google Scholar For our PPI discontinuation service, we first establish patient interest and eligibility. Patients ineligible for PPI discontinuation include those with Barret’s esophagus, Zollinger–Ellison disease, Los Angeles grade C or D erosive esophagitis, or idiopathic peptic ulcer disease. Other ineligible patients are those on nonselective NSAIDs at high risk of a GI bleed, those on COX-2 selective NSAIDs with a prior GI bleed, and those on antiplatelet therapy at high risk of a GI bleed. Once eligibility is determined, patients schedule a consult with a pharmacist to determine trigger foods and the potential need for supportive supplements on the basis of patient-specific symptoms. The patient’s daily PPI dose is converted to omeprazole equivalents to calculate the taper regimen that will be requested from the physician. If the patient receives 20 mg of omeprazole equivalent each day, their regimen will consist of omeprazole 15 mg for 2 weeks, omeprazole 10 mg for 2 weeks, and finally omeprazole 5 mg for 2 weeks. Patients are also provided with 5-mg capsules for breakthrough reflux symptoms. Follow-up with a pharmacist occurs by phone every 2 weeks to align with the time frame of the taper regimen. These phone calls assess patient symptoms and determine if any adjustments need to be made to the plan. We encourage patients to call the pharmacist whenever they need to report symptoms that are not responding to the breakthrough omeprazole. This project is under way, and as it progresses, we will collect metrics on frequency of rebound symptoms and success rate of discontinuation at 1, 3, and 6 months after conclusion of the PPI taper.