Patient Complexity Creates Barriers to PPI Deprescribing

A recent review of inappropriate prescribing among hospitalized older adults revealed that proton pump inhibitors (PPIs) follow only opiates and benzodiazepines as the most frequently misprescribed medications. In fact, up to 50% of PPI users either need not or should not be taking the drugs.

Although PPIs are generally well tolerated, high doses and long duration of use have been associated with more troublesome adverse drug reactions that include osteoporosis, pneumonia, and enteric infections.

For their small prospective feasibility study published in the November 2014 issue of Annals of Pharmacotherapy, a team of researchers from the University of South Wales attempted to determine whether systematic medication review and cessation of inappropriate medications, or deprescribing, could improve patient outcomes and reduce costs.

After developing a deprescribing process, the researchers looked for a medication class used to treat symptomatic conditions that could return after withdrawal and cause symptoms on abrupt cessation. PPIs fit the bill because they are associated with rebound acid hypersecretion (RAHS), the authors noted.

The researchers identified 57 PPI users with a mean age of 70 ± 14 years who were taking 14 ± 6 medications on average. Then, they employed a 5-step patient-centered deprescribing process in which pharmacists spearheaded (1) comprehensive medication history, (2) identification of potentially inappropriate medications, (3) assessment of medication cessation, (4) withdrawal regimen design, and (5) provision of monitoring, support, and documentation.

The authors found verifiable indications supporting PPI use in 43 participants, but they flagged PPI use as potentially inappropriate in 19 patients (44%). The participants were receptive to trying to reduce or discontinue their PPIs, especially after being reassured that they could restart the therapy if necessary.

The researchers assessed 8 participants as suitable for trial withdrawal, and 6 consented to it. All 6 successfully ceased or reduced their PPI use, and 4 were able to sustain the change in their medication regimens at 6 months following the interventions.

The researchers identified several barriers that made implementing the patient-centered describing process difficult, including incomplete medical histories, time limitations, and minimal evidence to support effectiveness in certain indications. As a result, they concluded that a deprescribing process can safely reduce inappropriate PPI prescribing in a small proportion of patients, but in a complex population, barriers tend to limit its use.