Toronto, Canada—New guidance from the American Gastroenterological Association (AGA) suggests that deprescribing of PPIs be considered in many cases and provides the best practice advice on how to do that.

Among the most commonly used medications in the world, PPIs were developed for the treatment and prevention of acid-mediated upper-gastrointestinal conditions. The AGA points out, however, that the drugs are increasingly used for indications where benefits are less clear.

"PPI overprescription imposes an economic cost and contributes to polypharmacy," according to an expert review published in the journal Gastroenterology. "In addition, PPI use has been increasingly linked to a number of adverse events (PPI-associated adverse events [PAAEs]). Therefore, de-prescribing of PPIs is an important strategy to lower pill burden while reducing real costs and theoretical risks."

The authors from the University of Toronto, Duke University in Durham, North Carolina, as well as the Veterans Affairs Center for Clinical Management Research and the University of Michigan, both in Ann Arbor, said their "...guiding principle was that, although PPIs are generally safe, patients should not use any medication when there is not a reasonable expectation of benefit based on scientific evidence or prior treatment response."

The authors advised that all patients taking a PPI should have a regular review of the ongoing indications for use and documentation of that indication by the primary care provider and that all patients without a definitive indication for chronic PPI should be considered for a trial of deprescribing.

The guidance also suggested that most patients with an indication for chronic PPI use who take twice-daily dosing should be considered for step-down to once-daily dosing of the PPI.

On the other hand, patients with complicated gastroesophageal reflux disease, such as those with a history of severe erosive esophagitis, esophageal ulcer, or peptic stricture, should generally not be considered for PPI discontinuation. This would also be the case for patients with known Barrett's esophagus, eosinophilic esophagitis, or idiopathic pulmonary fibrosis, the authors added.

In general, they explained, PPI users should be assessed for upper-gastrointestinal bleeding risk, and those at high risk should not be considered for PPI deprescribing.

In cases where the drug is discontinued, patients should be informed that they might develop transient upper-gastrointestinal symptoms due to rebound acid hypersecretion. That could vary on whether the dose is tapered or discontinued abruptly.

"The decision to discontinue PPIs should be based solely on the lack of an indication for PPI use, and not because of concern for PAAEs," the authors emphasize. "The presence of a PAAE or a history of a PAAE in a current PPI user is not an independent indication for PPI withdrawal. Similarly, the presence of underlying risk factors for the development of an adverse event associated with PPI use should also not be an independent indication for PPI withdrawal."

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