The Challenge of Discontinuing Proton Pump Inhibitors

Abstract

Proton pump inhibitors (PPIs) are among the most frequently prescribed medications associated with long-term cost. Indications, when known and documented, can include justifiable short-term therapy for eradication of H. pylori, healing of gastroesophageal erosions or peptic ulcer disease, and gastroprotection for concomitant erosive medications such as aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), or longer-term therapy for hypersecretory disorders such as Z€ ollinger-Ellison Syndrome. A murky but common use of PPIs is for symptoms associated with gastroesophageal reflux disease (GERD) and “stress ulcer prophylaxis.” On admission, nursing home residents are frequency prescribed PPIs as a continuation of therapy that was started in the community or during a recent hospitalization with an unclear indication for use. The ambiguous diagnosis of “stress ulcer prophylaxis” frequently accompanies residents admitted to the nursing home following hospital discharge. In 2006, the Centers for Medicare and Medicaid Services (CMS) included PPIs in Table 1 Unnecessary Drugs in the Guidance for Surveyors of Long-Term Care Facilities. 5 At that time, untoward consequences of PPI therapy reported in clinical trials were a 1% to 3% incidence of headache, nausea, diarrhea, skin rash, and constipation. Since then, the literature is replete with other potential adverse consequences of PPIs that include C. difficile diarrhea, pneumonia, hip fracture, hypomagnesemia and B12 deficiency. Despite that, we continue to see excessive PPI use lacking documentation of a diagnostic indication. What evidence is available to clinicians of nursing home residents to guide discontinuation of stress ulcer prophylaxis? Stress ulcers are acute superficial inflammatory lesions of the gastric mucosa induced when an individual is subjected to abnormally elevated physiologic demands. In