Missed Opportunities for Attempts at De-escalation of Proton Pump Inhibitor Therapy

Abstract

Introduction: Proton pump inhibitors (PPI) are one of the most widely prescribed classes of medication in the United States. Long term treatment with a PPI is appropriate in patients with Barrett's epithelium and a high risk for gastrointestinal (GI) bleeding. Attempts should be made to reduce or discontinue PPI use in individuals maintained on PPIs for other indications. This study evaluated the frequency of gastroenterologists' attempts to de-escalate PPI therapy when appropriate. Methods: A retrospective chart review of randomly selected records during a 1 year periods of patients prescribed a PPI >6 months seen by a gastroenterologist at an urban university medical center was conducted. Data was collected to determine the indication for PPI use, reason for clinic visit and documentation of a de-escalation discussion. De-escalation was defined as attempts at reduction in dose, reduction in frequency, or complete PPI discontinuation. Patients prescribed PPIs for Barrett's esophagus and GI bleeding were excluded. A Microsoft Excel database maintaining subject confidentiality was used. Statistical analysis performed using a two-tailed Fisher's Exact Test, with significance set at p < 0.05. Results: A total of 600 charts were initially reviewed, of which, 324 were included in the analysis. Of the 324 patients, 141 patients were prescribed a PPI by a gastroenterologist. 72 out of 141 were seen for GERD, and 69 seen for non-GERD reasons. 29 patients (40%) seen for GERD had documented discussions of de-escalation, compared to 12 (17%) of patients being seen for non-GERD reasons. There were more frequent attempts (p=0.0031) to de-escalate long-term PPI use when the patient was seen for GERD compared to when seen for a non-GERD indication. Conclusion: It is recommended that patients maintained on long term PPIs without an indication for chronic use should have an attempt to de-escalate their therapy. Our data show that gastroenterologists more consistently attempt PPI de-escalation when patients are seen for GERD management compared to when patients have appointments for non-GERD conditions (40% vs 17%, p=0.0031). While PPIs are quite safe, and overall, well tolerated, potential adverse effects have been well documented. There may be missed opportunities to de-escalate of discontinue PPI use in patients on chronic PPI treatment when seen in clinic for management of non-GERD conditions.