Should Your Facility Have a Low Threshold for De-Prescribing PPIs?

Pantoprazole and other proton pump inhibitors (PPIs) are commonly started in the acute hospital setting and then continued in the post-acute and long-term care (PALTC) setting of care without a clear ongoing indication.  PPIs have an acid rebound withdrawal syndrome, so patients previously without GI acid symptoms may develop them, if PPIs are abruptly stopped, reinforcing the patient’s perception that they now need a PPI. 

Fortunately, we now have a large high-quality study in JAMA that no longer supports the routine use of 3 days of PPIs in the ICU setting for reducing the risk of stress ulcers in patients requiring ventilator support.  This study found a consistent higher mortality in PPI users vs. H2 Blockers (histamine-2 receptor antagonists), e.g., ranitidine or famotidine).  The accompanying JAMA editorial agreed and noted that the slightly higher risk of GI bleeds can be well managed by converting an H2 blocker to a PPI if a stress ulcer bleed develops.  I found the accompanying JAMA video to be quite informative.

In the JAMA study, the patients with the highest mortality on PPIs were the sickest patients.  The study author suggested that the increased mortality may be due to the increased risk of gram negative pneumonia as well as other immune system deficits.  

Historically, the early evidence of reduced stress ulcer-associated UGI bleeds in the ICU setting was used to justify the use of PPIs in medical and surgical adult patients managed on the hospital wards, though there have never been subsequent studies to support that assumption.  In my community, this has led to the initiation of PPIs in most hospitalized adults and then the continuation of these agents on discharge to SNFs or home. 

With the above study results in, it’s time for the acute hospital team to reduce their over-prescribing of PPIs and for SNFs to consider de-prescribing them.

Besides this new evidence of adverse mortality effect with acute use, chronic use has been associated with increased risk for gram-negative pneumonia, Clostridioides (formerly Clostridium) difficile colitis, hypomagnesemia, hip fractures, and Vitamin B-12 deficiency.  In chronic use, PPIs should be tapered by half doses every 2-4 weeks to reduce the risk of rebound hyperacidity symptoms.

The ABIM “Choosing Wisely” Campaign has now created a free app by the same name available on Apple and Android smartphones.  It’s an easy to use app and has information for clinicians and patients that’s quite helpful.  I put into the search engine “Proton Pump Inhibitors” and saw information from the American Gastroenterological Association on this subject that supported minimizing the use of PPIs from a clinician’s and a patient’s perspective.  

A facility PPI de-prescribing QAPI project should lower pharmaceutical costs and reduce the costs associated with managing their complications.  Teaming up with referring hospitals should enhance the effectiveness of this project.

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