Peter J Zed
Deprescribing is the planned and supervised process of dose reduction or discontinuation of a medication that may cause harm or that may no longer be providing benefit to a patient.1 Deprescribing reduces polypharmacy while minimizing the risk of adverse events caused by unnecessary medications. Although deprescribing strategies should be applied to all patients, older adults are often the target population because of their higher risk of adverse drug events.
Proton pump inhibitors (PPIs) are one of the most commonly prescribed classes of medication. They are used to treat a variety of gastrointestinal indications, including gastro-esophageal reflux disorder, peptic ulcer disease, Barrett esophagus, esophagitis, and gastritis; they are also used as gastroprotection for patients receiving long-term therapy with nonsteroidal anti-inflammatory drugs. Although PPIs are a relatively safe class of medications, their use carries certain risks, particularly with long-term use. The risks of long-term PPI use include fractures, pneumonia, enteric infections, hypomagnesemia, acute interstitial nephritis, and vitamin B12 deficiency.2 In a national modified Delphi consensus process, PPIs were selected as a target medication class for deprescribing strategies because of their high prevalence of both use and overuse.3
This issue of the Canadian Journal of Hospital Pharmacy includes 3 papers that highlight ongoing issues with PPIs and evaluate the impact for patients for whom PPIs are being prescribed and those who are using PPIs on a long-term basis. Chan and others4 retrospectively evaluated the appropriateness of PPI use among patients in residential care facilities in British Columbia.4 They found that among 407 PPI orders for 334 patients, 16% did not have any of the broad evidence-based indications for use, as defined by the study’s authors, and 44% did not have a common evidence-based indication for use (i.e., gastroesophageal reflux disorder or peptic ulcer disease). Doell and others5 retrospectively evaluated the charts of 147 residents of long-term care facilities to determine their eligibility for PPI deprescribing. In addition, they evaluated vitamin B12 deficiency and fall risk in the study population. They found that 63% of the residents were candidates for PPI deprescribing. Among those residents, 20% did not have any identifiable indication for PPI use. Although no causal relationship or consequences were established in this study, 9% of the residents had experienced a fall within the previous 30 days, and 36% were receiving vitamin B12 supplements or had low serum vitamin B12 levels. In the third study, Wan and others6 characterized the appropriateness of PPI orders initiated or continued in a population of internal medicine and family practice inpatients. They also evaluated potential adverse events associated with PPI use and the impact of an educational intervention to improve prescribing. This chart review showed that 36% of the 258 patients did not have any indication for PPI. Community-acquired pneumonia and Clostridium difficile infections were the most common adverse events potentially associated with PPI use. Finally, the authors’ survey of health care professionals showed that a multidisciplinary educational intervention improved PPI prescribing for more than half of respondents.
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This important series of studies, conducted in 3 distinct patient populations, illuminates the issue of PPI deprescribing, and challenges pharmacists to play a role in appropriate use of these drugs. Every patient, in any setting, for whom a PPI is being prescribed and all those who are receiving a PPI on a long-term basis should undergo an assessment for appropriate use. A recently published evidence-based clinical practice guideline can help clinicians to make decisions about when and how to deprescribe PPIs.7 In addition, a toolkit for deprescibing PPIs has been developed by the Choosing Wisely Canada campaign.8 Together, these resources are valuable tools for all health care providers, presenting details on the appropriate indications for and duration of PPI therapy, the long-term risks of using a PPI, strategies to engage patients and health care providers, and thorough deprescribing algorithms. In addition, the Choosing Wisely Canada toolkit provides useful and practical performance measures that hospitals and related health care settings can use to evaluate interventions associated with PPI prescribing and deprescibing.
Pharmacists are the optimal health care professionals to provide leadership in appropriate use of all medications. Although this issue of the Journal focuses on deprescribing PPIs, we should always be exploring opportunities to improve medication use and thereby enhance the health outcomes of our patients.
1 Thompson W, Farrell B. Deprescribing: what it is and what does the evidence tell us? Can J Hosp Pharm. 2013;66(3):201–2.
2 Maes ML, Fixen DR, Linnebur SA. Adverse effects of proton pump inhibitor use in older adults: a review of the evidence. Ther Adv Drug Saf. 2017;8(9):273–97.
3 Farrell B, Tsang C, Raman-Wilms L, Irvirg H, Conklin J, Pottie K. What are the priorities for deprescribing for elderly patients? Capturing the voice of practitioners: a modified Delphi process. PLoS One. 2015:10(4):e0122246.
4 Chan A, Liang L, Tung ACH, Kinkade A, Tejani AM. Is there a reason for the proton pump inhibitor? An assessment of prescribing for residential care patients in British Columbia. Can J Hosp Pharm. 2018;71(5):295–301.
5 Doell A, Walus A, To J, Bell A. Quantifying candidacy for deprescribing of proton pump inhibitors among long-term care residents. Can J Hosp Pharm. 2018;71(5):302–7.
6 Wan A, Halpape K, Talkhi SC, Dixon C, Dossa H, Tabamo J, et al. Evaluation of prescribing appropriateness and initiatives to improve prescribing of proton pump inhibitors at Vancouver General Hospital. Can J Hosp Pharm. 2018;71(5):308–15.
7 Farrell B, Pottie K, Thompson W, Boghossian T, Pizzola L, Rashid FJ, et al. Deprescribing proton pump inhibitors. Evidence-based clinical practice guideline. Can Fam Physician. 2017;63(5):354–64.
8 Bye-bye, PPI. A tookit for deprescribing proton pump inhibitors in EMR-enabled primary care settings. Version 1.2. Choosing Wisely Canada; 2017 Jul [cited 2018 Aug 16]. Available from: https://choosingwiselycanada.org/perspective/ppi-toolkit/
Competing interests: None declared. ( Return to Text )
Address correspondence to: Dr Peter J Zed, Faculty of Pharmaceutical Sciences, University of British Columbia, 2405 Wesbrook Mall, Vancouver BC V6T 1Z3, e-mail:peter.zed@ubc.ca
Canadian Journal of Hospital Pharmacy, VOLUME 71, NUMBER 5, September-October 2018