AGA clinical practice update offers guidance on PPI deprescribing

The American Gastroenterological Association (AGA) recently offered advice on use of and deprescribing of proton-pump inhibitors (PPIs) in ambulatory patients.

The drugs are often used for indications with unclear benefits, with increasing links to adverse events, the AGA clinical practice update said. To provide best practice advice (BPA) statements on PPI deprescribing, the panel identified three key domains for recommendations: documentation of PPI indication, identification of suitable candidates for consideration of deprescribing, and optimization of successful deprescribing. The guidance was not based on a systematic review, so the quality of the evidence and the strength of the recommendations were not formally rated. The BPA statements were published Feb. 16 by Gastroenterology.

All patients taking a PPI should have a regular review and documentation of the ongoing indications for use, and this review should be the responsibility of their primary care clinician, the clinical practice update said. All patients without a definitive indication for chronic PPI use should be considered for trial of deprescribing.

Most patients with an indication for chronic PPI use who take twice-daily dosing should be considered for stepdown to once-daily dosing, the update said. PPI discontinuation should generally not be considered in patients with complicated gastroesophageal reflux disease, such as a history of severe erosive esophagitis, esophageal ulcer, or peptic stricture. In addition, a trial of deprescribing should generally not be considered in patients with known Barrett's esophagus, eosinophilic esophagitis, or idiopathic pulmonary fibrosis, the update said.

Patients who take PPIs should be assessed for upper GI bleeding risk with an evidence-based strategy before deprescribing, and PPI deprescribing should not be considered for patients at high risk for upper GI bleeding. Patients who discontinue long-term PPI therapy should be advised that they may develop transient upper GI symptoms due to rebound acid hypersecretion, the update said. When PPIs are deprescribed, dose tapering or abrupt discontinuation can be considered.

Finally, the update noted, the decision to discontinue PPIs should be based solely on the lack of an indication for PPI use, not on concern for PPI-associated adverse events. The presence or history of these events in a patient currently taking PPIs is not an independent indication for PPI withdrawal, it said, nor should underlying risk factors for an adverse event be an independent indication for withdrawal.

The update authors noted that decisions about discontinuing PPIs are complex and nuanced and that inappropriate or poorly considered discontinuation can have significant consequences. However, they said that PPI use when indications are absent or unclear contributes to health care costs and that a small risk of harm can be significant when benefit is lacking.

“We also recognize that PPI discontinuation requires a systematic approach, and that patients and their [primary care clinicians] may not have the tools or resources to undertake this task in the face of competing medical concerns,” the authors wrote. “We are hopeful that these BPA statements will be valuable to the clinician and patient in providing guidance for approach and decision making about this issue. We also encourage physicians to partner with pharmacists to implement these BPAs in their clinical settings.”