Many Internists Inappropriately Advise Stopping PPI Therapy

Most internists would recommend discontinuation of proton-pump inhibitors (PPIs) after long-term use whether or not it is appropriate, according to a national survey.

"I was really surprised at just how often the internists in our survey recommended stopping the PPI in a patient at high risk for bleeding," said Dr. Jacob E. Kurlander from Veterans Affairs Ann Arbor Healthcare System and the University of Michigan.

"PPIs are really wonder drugs when it comes to their ability to treat and prevent upper GI bleeding, but we're still sorting out as a profession how to make sure they are used to the greatest benefit of our patients," he told Reuters Health by email.

In the face of reports linking PPIs to numerous adverse events, the American Board of Internal Medicine's Choosing Wisely campaign in 2012 conditionally recommended dose reductions or discontinuation of PPIs in some patients with gastroesophageal reflux disease (GERD).

A survey the next year found that internists inappropriately recommended stopping PPIs used for the prevention of upper gastrointestinal bleeding (UGIB) more often than they appropriately recommended stopping PPIs when used for GERD.

Now that PPIs have been linked to other serious conditions (chronic kidney disease, dementia, and excess risk of death) and deprescribing guidelines have been published, Dr. Kurlander and colleagues conducted an online national survey of physician members of the American College of Physicians to determine how they perceive the adverse effects associated with PPIs and whether or not they are appropriately changing their prescribing and deprescribing practices.

The survey included a 34-item multiple-choice questionnaire and four common clinical scenarios involving a 70-year-old female patient who uses omeprazole 20 mg daily and has recently been diagnosed with osteopenia. The scenarios varied in the hypothetical patient's UGIB risk. The response rate was 55%, with 437 internists responding.

Two-thirds reported familiarity with guidance on appropriate use of PPIs to prevent UGIB, 52% perceived PPIs to be somewhat/very effective for UGIB prevention, and 93% reported being somewhat or very familiar with published data on PPI adverse events.

Seventy percent of the respondents were somewhat or very concerned about adverse events when prescribing PPIs, and 76% had somewhat or very much changed their prescribing practices for PPIs.

In the GERD scenario in which PPI could be safely discontinued, 86% of respondents appropriately recommended PPI discontinuation, including 55% who recommended switching to an H2 blocker like ranitidine.

However, an overwhelming majority of internists also recommended discontinuing PPI therapy in patients at low risk (92%), moderate risk (87%), or high risk (79%) of UGIB, the researchers report in The American Journal of Gastroenterology.

In multivariable analysis, the odds of PPI continuation were strongly associated with the internists' perceived effectiveness of PPI for preventing UGIB.

Only 5% of participants who reported that PPIs were not at all or only slightly effective for preventing UGIB recommended PPI continuation; the odds of PPI continuation were 7.68-fold higher among those who perceived PPIs to be moderately effective and 17.3-fold higher among those who perceived PPIs to be very effective.

Concern about PPI adverse events, on the other hand, had no significant association with PPI continuation. Neither did age, gender, trainee status, patient volume, availability of decision support for appropriate PPI use, or familiarity with guidelines.

"We need to be really thoughtful about when we stop patients' PPIs," Dr. Kurlander said. "Stopping in the wrong patient can definitely incite gastrointestinal bleeding. We've actually published a case just like that of the patient in our high-risk GI bleed scenario."

"And to take this further, we need to develop implementation strategies to ensure that patients who are high-risk get started on PPIs in the first place," he said. "Most high-risk patients are never started on a PPI."

Dr. Kurlander added, "One rule of thumb is the TUNA 2 rule: any patient with any two of the following risk factors should be on a PPI for gastroprotection: thienopyridines, upper GI bleeding or ulcer history, NSAIDS, aspirin, and anticoagulants. You can also include advancing age (especially over 70) on that list."

Dr. Einar S. Bjoernsson of Landspitali—The National University Hospital of Iceland, in Reykjavik, who recently reviewed problems associated with deprescribing PPIs, told Reuters Health by email, "There is both overuse but also underuse of PPIs. As a gastroenterologist from the US said, 'Those who are on a PPI should not be on it, but those who are not on it should be on it.'"

"Physicians should consider the indication for the drug," said Dr. Bjoernsson. who was not involved in the study. "If the patient has an adequate indication, this outweighs the potential adverse effects. PPIs should be used for an adequate indication as all other drugs, for the shortest time possible and at the lowest dose that keeps symptoms away (most often GERD)."

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