Review Provides Recommendations for Effective PPI Discontinuation
A recent review published in the journal Current Gastroenterology Reports provides evidence-based strategies on how to effectively discontinue proton pump inhibitor (PPI) therapy.
PPIs are one of the most widely prescribed classes of drugs, however long-term use of these agents has been associated with increased risks such as Clostridium difficile infection, osteoporosis, pneumonia, vitamin deficiency, and dementia (Freedberg DE et al, 2017; Gomm W et al 2016). According to the review, a substantial number of patients can effectively decrease or completely discontinue use of PPIs, as often these agents are prescribed without an appropriate reason.
One 2010 study (Heidelbaugh JJ et al) found that just 35.4% of patients at a VA clinic received PPI therapy for appropriately documented reasons. As such, the authors recommend clinicians objectively qualify the indication for PPI use. Patients with clear indications (i.e., Barrett's esophagus, gastroesophageal reflux disease [GERD] with esophagitis, dual antiplatelet therapy with gastrointestinal [GI] bleed risk factors) should then be informed of the low absolute risk of continued PPI use. However, “patients with uncomplicated GERD or other indications such as functional dyspepsia should have an attempt at dose reduction or discontinuation if possible,” the authors write.
To avoid rebound symptoms when patients attempt discontinuation, a 'step-down' method may be adopted, with the dose halved over 2 weeks to a month (when the rate of symptom recurrence is highest). Alternate day treatment may be considered for those patients already on the lowest daily dose.
While multiple studies (Inadomi JM et al, 2001; Bjornsson E et al, 2006) have demonstrated that PPI tapering is associated with a greater percentage of discontinuation, Bjornsson et al found that only 21% and 48% of GERD and non-GERD patients remained off PPIs at the 1-year follow-up (P=.59). This suggests that higher serum gastrin in GERD patients may indicate a higher rebound risk that may require a longer tapering strategy.
Prescribing alternative therapies (i.e., alginate, histamine receptor antagonists) may help with breakthrough symptoms. In addition, on-demand PPI therapy, where patients resume treatment only when symptoms recur and discontinue when symptoms subside, has been shown to be a successful and cost-effective strategy for limiting PPIs.
With regard to reflux hypersensitivity, the authors recommend ambulatory pH or pH-impedance testing to distinguish between this condition and GERD; treatments such as selective serotonin reuptake inhibitors and tricyclic antidepressants may be more effective for these patients.
"Overall, the strategies reviewed [...] vary in their methods and confirmatory evidence. However, they all support the idea that a substantial number of patients can decrease or discontinue their PPIs effectively," conclude the authors.
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