129: Let’s Take It Down a Notch: Deprescribing PPIs

In episode 57, we had in depth discussion of safety issues, general use and recommendations for PPI therapy. In this episode, we briefly review PPI safety concerns and focus on strategies to deprescribe proton pump inhibitors.

Key Concepts

1. PPIs are approved as acid-reducing therapies to treat various conditions related to decreased gastric pH, however, undocumented use of PPI has increased over the years.
2. For indicated conditions, PPI should be used at lowest dose for shortest duration possible.
3. When used for longer than intended duration, PPIs may cause long-term issues such as hypomagnesemia, low vitamin B12 levels, low iron levels, anemia, C. difficile-associated diarrhea (CDAD), chronic kidney disease (CKD), and hypergastrinemia causing rebound acid hypersecretion.
4. Options for limiting PPI use are: abrupt discontinuation, dose reduction, on-demand dosing, slow deprescribing, or switching to alternate therapy. Abrupt discontinuation leads to rebound hypersecretion due to high gastrin levels.
5. There is lack of substantial evidence for what deprescribing strategy is better, but decreasing from multiple times a day to single daily dose, reducing the single daily dose, and switching to every other day are all appropriate strategies.

References

• Farrell B, Pottie K, Thompson W, et al. Deprescribing proton pump inhibitors. Evidence-based clinical practice guideline. Can Fam Physician. 2017 May; 63(5): 354–364.
• https://deprescribing.org/resources/deprescribing-guidelines-algorithms/ - Specific recommendations for deprescribing certain medications or medication classes