Patient Values and Preferences Surrounding Proton Pump Inhibitor Use: A Scoping Review

Primary and Specialty Care Trainees' Perceptions About Proton Pump Inhibitor Use

OBJECTIVE

Proton pump inhibitors (PPIs) are widely prescribed with proven efficacy in many indications, yet longstanding controversy about potential adverse events persists. We aimed to acquire knowledge about perceptions of outpatient PPI long-term prescribing (≥8 wk) among primary and specialty care trainees at 2 Canadian Universities.

METHODS

Family medicine, internal medicine, and gastroenterology trainees completed a web-based survey that included 20 clinical scenarios assessing trainee knowledge about PPI efficacy. Contextual PPI prescribing decisions were also elicited, balancing possible PPI indications versus side effects. Management strategies were compared between junior and senior trainees, as well as across training programs.

RESULTS

Over a 4-month period,163 trainees (age <26 y: 12%; age 26 to 45: 88%; 59% females) participated in the survey (family medicine: 51%, internal medicine: 44%, and gastroenterology: 5%); 83% were considered junior residents. Only 42% had received formal education on prescribing PPI long-term. Overall, 93% believed they would benefit from such teaching, with 98% stating they would follow related guidelines. No between-group differences were noted in knowledge of appropriate PPI indications nor possible side effects when comparing juniors to seniors, or among different specialties. Across different management scenarios, inappropriate PPI discontinuation was chosen by 14.3% to 67.2%, whereas inappropriate PPI continuation was reported in up to 57%. Trainee seniority and specialty did not differ in appropriate deprescribing rates.

CONCLUSIONS

Training level and primary versus specialty care settings are associated with frequent inappropriate PPI prescribing and deprescribing. These findings highlight the need for and may inform future educational programs on PPI usage.

American Society for Gastrointestinal Endoscopy guideline on the diagnosis and management of GERD: summary and recommendations

This clinical practice guideline from the American Society for Gastrointestinal Endoscopy (ASGE) provides an evidence-based approach for strategies to diagnose and manage GERD. This document was developed using the Grading of Recommendations Assessment, Development, and Evaluation framework and serves as an update to the 2014 ASGE guideline on the role of endoscopy in the management of GERD. This updated guideline addresses the indications for endoscopy in patients with GERD as well as in the emerging population of patients who develop GERD after sleeve gastrectomy or peroral endoscopic myotomy. It also discusses how to endoscopically evaluate gastroesophageal junctional integrity in a comprehensive and uniform manner. Importantly, this guideline also discusses management strategies for GERD including the role of lifestyle interventions, proton pump inhibitors (PPIs), and endoscopic antireflux therapy (including transoral incisionless fundoplication [TIF], radiofrequency energy, and combined hiatal hernia repair and TIF [cTIF]) in the management of GERD. The ASGE suggests upper endoscopy for the evaluation of GERD in patients with alarm symptoms, with multiple risk factors for Barrett's esophagus, and with a history of sleeve gastrectomy. The ASGE recommends careful endoscopic evaluation, reporting, and photo-documentation of objective GERD findings with attention to gastroesophageal junction landmarks and integrity in patients who undergo upper endoscopy to improve care. In patients with GERD symptoms, the ASGE recommends lifestyle modifications. In patients with symptomatic and confirmed GERD with predominant heartburn symptoms, the ASGE recommends medical management including PPIs at the lowest dose for the shortest duration possible while initiating discussion about long-term management options. In patients with confirmed GERD with small hiatal hernias (≤2 cm) and Hill grade I or II who meet specific criteria, the ASGE suggests evaluation for TIF as an alternative to chronic medical management. In patients with persistent GERD with large hiatal hernias (> 2cm) and Hill grade III or IV, the ASGE suggests either cTIF or surgical therapy based on multidisciplinary review. This document summarizes the methods, analyses, and decision processes used to reach the final recommendations and represents the official ASGE recommendations on the above topics.

Polypharmacy and Deprescribing in Older Adults

Older adults commonly end up on many medications. Deprescribing is an important part of individualizing care for older adults. It is an opportunity to discuss treatment options and revisit medications that may not have been reassessed in many years. A large evidence base exists in the field, suggesting that deprescribing is feasible and safe, though questions remain about the potential clinical benefits. Deprescribing research faces a myriad of challenges, such as identifying and employing the optimal outcome measures. Further, there is uncertainty about which deprescribing approaches are likely to be most effective and in what contexts. Evidence on barriers and facilitators to deprescribing has underscored how deprescribing in routine clinical practice can be complex and challenging. Thus, finding practical, sustainable ways to implement deprescribing is a priority for future research in the field.

Efficacy of a computer based discontinuation strategy to reduce PPI prescriptions: a multicenter cluster-randomized controlled trial

Deprescribing of inappropriate long-term proton pump inhibitors (PPI) is challenging and there is a lack of useful methods for general practitioners to tackle this. The objective of this randomized controlled trial was to evaluate the effectiveness of the electronic decision aid tool arriba-PPI on reduction of long-term PPI intake. Participants (64.5 ± 12.9 years; 54.4% women) with a PPI intake of at least 6 months were randomized to receive either consultation with arriba-PPI from their general practitioner (n = 1256) or treatment as usual (n = 1131). PPI prescriptions were monitored 6 months before, 6 and 12 months after study initiation. In 49.2% of the consultations with arriba-PPI, the general practitioners and their patients made the decision to reduce or discontinue PPI intake. At 6 months, there was a significant reduction by 22.3% (95% CI 18.55 to 25.98; p < 0.0001) of defined daily doses (DDD) of PPI. A reduction of 3.3% (95% CI - 7.18 to + 0.62) was observed in the control group. At 12 months, the reduction of DDD-PPI remained stable in intervention patients (+ 3.5%, 95% CI - 0.99 to + 8.03), whereas control patients showed a reduction of DDD-PPI (- 10.2%, 95% CI - 6.01 to - 14.33). Consultation with arriba-PPI led to reduced prescription rates of PPI in primary care practices. Arriba-PPI can be a helpful tool for general practitioners to start a conversation with their patients about risks of long-term PPI intake, reduction or deprescribing unnecessary PPI medication.

Appropriateness of proton pump inhibitor therapy in an ambulatory geriatrics clinic: A retrospective cross-sectional analysis

Background

Proton pump inhibitors are considered potentially inappropriate medications in the geriatric population. The use of proton pump inhibitors by older adults has increased over the past several decades; however, existing literature suggests that only one-third of patients prescribed these medications have a valid indication for use. The aim of this study was to assess the appropriateness of proton pump inhibitor therapy in a population of ambulatory geriatric patients and to determine the impact of an interdisciplinary clinic on their use.

Methods

This was a retrospective, cross-sectional study of patients referred to an ambulatory geriatrics clinic between October 2017 and March 2021. Participants were eligible for inclusion if they were taking a proton pump inhibitor at the time of clinic admission. Appropriateness of proton pump inhibitor therapy was assessed based on indication and dosing regimen.

Results

In total, 280 participants were included. The mean age was 79.6 years (SD 7.7) and 60% were female. Overall, 94 of 280 (33.6%) participants had a documented valid indication for their proton pump inhibitor. The clinic team intervened to reduce the dose or discontinue 76 of 186 (40.8%) inappropriate proton pump inhibitors.

Interpretation

Only one-third of proton pump inhibitors used by ambulatory geriatric patients have a documented appropriate indication for use. Given the medical complexity of this population and their vulnerability to adverse effects, the ambulatory geriatric population should be a priority target for proton pump inhibitor deprescribing initiatives.

Encouraging appropriate use of proton pump inhibitors: existing initiatives and proposals for the future

INTRODUCTION

Proton pump inhibitors (PPIs) have revolutionized the management of acid-related disorders, representing today the mainstay treatment of these conditions. However, despite their large range of indications and usefulness, the remarkable expansion of their use in the last two decades cannot be explained by the increasing prevalence of acid-related diseases only. An inappropriate prescription for clinical conditions in which the pathogenetic role of acid has not been documented has been described, with the natural consequence of increasing the costs and the potential risk of iatrogenic harm due to adverse events and complications recently emerged.

AREAS COVERED

In this review, we summarize current indications of PPIs administration, potential adverse events associated with their chronic utilization, and misuse of PPIs. Moreover, we describe existing and possible initiatives for improving the use of PPIs, and some proposals for the future.

EXPERT OPINION

PPI deprescribing is the preferred and most effective approach to reduce the use of PPIs, rather than adopting sharp discontinuation, probably due to fewer withdrawal symptoms. Nonetheless, large knowledge gaps still exist in clinical practice regarding the optimal approach of PPI deprescribing in various clinical scenarios. Further prospective well-designed international studies are eagerly warranted to improve our perspectives on controlling global PPI inappropriate use.

Deprescribing antacids after the diagnosis of Clostridioides difficile infection: A single-center observational study

Overuse of antacids is associated with the development and recurrence of Clostridioides difficile infection (CDI). Discontinuation of unnecessary antacids for CDI management is advocated; however, the clinical pervasiveness on the discontinuation of antacids remains unclear. We conducted a single-center retrospective observational study to determine the rate of antacid discontinuation following CDI diagnosis. Among 51 patients (58 infections; median age 76.5 years, range 69-82; 53.5% women) treated with antimicrobials against C. difficile, 41 had been treated with antacids, and of these, 18 exhibited no indication for antacid administration. However, none had discontinued antacid use. While CDI provides an opportunity for antacid stewardship, it is not implemented in clinical practice. In addition to the efforts of individual clinicians, the dissemination of knowledge of the indications and side effects of antacids, establishment of a multidisciplinary support system, and creation and implementation of a clinical stewardship pathway are necessary to increase the deprescription of antacids in patients with CDI.

Patients' perspectives on a patient-oriented electronic decision support tool to reduce overuse of proton pump inhibitors (arriba-PPI): a qualitative study in primary care

BACKGROUND

To evaluate patients' perspectives and their experiences with a consultation involving a computer-assisted and patient-centered discontinuation strategy (arriba-PPI tool) as part of a German multicenter study on reducing the prescription of proton pump inhibitors (PPIs).

METHODS

Qualitative in-depth telephone interviews on proton pump inhibitors with patients who had received an arriba-PPI tool-based counseling by their general practitioner (GP). A random sample of 30 patients was taken from study participants. Interviews were conducted in 2020 and analyzed using a thematic qualitative text analysis.

RESULTS

Although this was meant to be the key to shared decision making with regard to PPI reduction, study participants mostly did not recall the visual features of the tool. However, a few patients remembered them very clearly. Above all, patients appreciated a trustful relationship with the GP as well as comprehensive, individualized counseling.

CONCLUSION

Application of the arriba-PPI tool can support the decision process but can also hinder the consultation process if the tool is not properly embedded in the consultation. GPs using the arriba-PPI tool to support the shared decision-making process should consider the patients' and their own expectations on the benefit of the visual representation of the tool.

Development of Patient Education Material for Proton Pump Inhibitor Deprescribing: A Mixed-Methods Study

BACKGROUND

Proton pump inhibitor (PPI) deprescribing is recommended in case of inappropriate use. Patient education materials are key elements in the deprescribing process.

OBJECTIVE

The study objective was to develop patient education material for PPI deprescribing in primary care in France.

METHODS

This was a mixed-methods study involving (1) a literature review of the existing patient education materials on PPI deprescribing to identify key points to optimize the layout and content of the document; (2) development of a first version of the brochure by a pluri-professional steering group, following the national reference methodology of the French National Authority for Health (Haute Autorité de Santé) and iterative modifications of the patient brochure; (3) assessment of the content and understandability of the brochure by questionnaires followed by semistructured interviews with target patients; and (4) iterative brochure readability assessment with the Flesch reading ease tool.

RESULTS

The final patient education material is a double-sided A3 brochure-that is, 4 A4 pages. The first round of user testing by questionnaire (n = 14 patients) led to modifications to improve the document understandability, validated in the second round of user testing by questionnaire (n = 10 patients). The semistructured interviews (n = 10 patients) highlighted an adequate comprehension, whereas actionability required some minor modifications. The readability test score of the final education brochure was 59.4.

CONCLUSION AND RELEVANCE

This patient education brochure for PPI deprescribing is targeted to patients in primary care. Its impact on PPI deprescribing will be assessed in a population-based pragmatic trial in primary care.

Opportunities for successful de-escalation of proton pump inhibitors at a federally qualified health center

Background

A Proton Pump Inhibitor (PPI) de-escalation initiative was piloted at a Family Medicine Federally Qualified Health Center (FQHC) after a needs assessment showed that PPIs were prescribed inappropriately. The objective was to evaluate implementation of a PPI de-escalation program for an urban, underinsured patient population at a (FQHC).

Methods

Patients receiving PPI with an upcoming appointment with their primary care provider (PCP) were evaluated by a pharmacist for the appropriateness of therapy. The pharmacist administered a questionnaire to patients to assess PPI usage patterns and then evaluated for appropriate PPI therapy which included diagnoses, risk factors for gastrointestinal bleed, symptom control, and duration of PPI therapy. For consenting patients, de-escalation was implemented per pharmacist protocol.

Results

A total of 36 patients were evaluated for appropriate PPI use, among those, 21 (58%) were eligible for de-escalation, and 19 agreed to de-escalation. Fifteen patients (15/19) had successful PPI de-escalation after 4 weeks without discomfort or symptoms which disrupted daily activities.

Conclusions

This pharmacist led initiative in collaboration with PCPs resulted in successful de-escalation of PPIs in an underserved primary care setting.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40360-021-00486-x.

Impact of pharmacy-supported interventions on proportion of patients receiving non-indicated acid suppressive therapy upon discharge: A systematic review and meta-analysis

Objective

Conduct a systematic review and meta-analysis to estimate the impact of pharmacy-supported interventions on the proportion of patients discharged from the hospital on inappropriate acid suppressive therapy (AST).

Methods

To identify studies, the following databases were systematically searched on October 14^th, 2018 and repeated on September 12^th, 2019: Ovid MEDLINE(R) and In-Process & Other Non-Indexed Citations and Daily, Embase.com, CINAHL, Web of Science, Cochrane CENTRAL (EBSCO), and ClinicalTrials.gov. Eligible studies consisted of adults, intervention and historical/usual care groups, description of active pharmacy-supported intervention, and proportion of patients discharged on inappropriate AST. Qualitative assessments and quantitative analyses were performed. Modified funnel plot analysis assessed heterogeneity. Preferred reporting items of systematic reviews and meta-analyses (PRISMA) methodology was used to evaluate studies in this review.

Results

Seventeen publications resulting in 16 studies were included in the review. Using random effects model, meta-analysis showed a significant reduction in the odds of being discharged on inappropriate AST from the hospital in the pharmacist-supported intervention arm versus comparator (Odds Ratio 0.33 [95%CI 0.20 to 0.53]), with significant heterogeneity (I² = 86%). Eleven studies favored pharmacy-supported interventions, four were inconclusive and one favored usual care. Using modified funnel plot analysis, our final evaluation was distilled to 11 studies and revealed a similar outcome (OR 0.36 [95%CI 0.27 to 0.48]), but with less heterogeneity (I² = 36%).

Conclusion

This systematic review and meta-analysis showed that pharmacy-supported interventions were associated with a significantly reduced probability of patients discharged on inappropriate AST. However, heterogeneity was high and may affect interpretation of results. Using funnel plot optimization method, three positive and two negative studies were objectively removed from analyses, resulting in a similar effect size, but with less heterogeneity. To improve study quality, future researchers should consider utilizing a pre-post, multi-arm, prospective design with sampling randomization, training of data extractors (preferably two extractors), re-evaluating a small dataset to check for agreement and providing a comprehensive methodology in subsequent publications.

Patient Awareness of Reported Adverse Effects Associated with Proton Pump Inhibitors in a Medically Underserved Community

Reports of adverse effects associated with proton pump inhibitors (PPIs) are concerning because of high usage and over-the-counter availability. We sought to determine the awareness of PPI adverse effects among our patient population, which is medically underserved, low-income, and racially diverse. A 21-item survey was administered to gastroenterology-clinic outpatients. It collected information about age, gender, education, race, specialty of the prescriber, specific PPI, indication, knowledge of dose, adherence, duration of use and awareness of any risks. Medical records were reviewed to verify survey responses pertaining to indication, dosing, and adherence. A vast majority (96%) of 101 participants were not aware of PPI adverse effects. In total, 63% of the patients completed a high school education or less, which was associated with a higher risk of long-term PPI use than completion of at least an undergraduate degree (p = 0.05). In contrast to other studies, the shockingly low patient awareness about PPI adverse effects in our patient population is particularly concerning, especially as it is tied to their demographic attributes. This may lead to long-term and high-dose PPI use. Our study highlights the need for effective provider-driven education regarding medication risks, especially in the communities with significant health disparities.

Discussing proton pump inhibitor deprescribing: the views of Danish GPs and older patients

Background

Deprescribing of proton pump inhibitors (PPIs) can be considered in situations where the drug may no longer be necessary; however, this requires a careful discussion between patients and healthcare providers, often general practitioners (GPs). The aim of our study was to explore how GPs discuss PPI deprescribing with patients and compare that to how older patients would like to discuss this decision.

Methods

We conducted a qualitative study using semi-structured interviews with GPs (n = 11) and patients aged ≥65 years who were taking PPIs (n = 4). Analysis of interviews was based on systematic text condensation.

Results

We identified four main themes: (1) Reasons PPI deprescribing comes up, (2) Considering PPI deprescribing, (3) Discussion topics, and (4) Incorporating patient preferences into PPI deprescribing decisions. We found that PPI deprescribing often comes up during consultations for other problems or due to concern about medication burden in general. GPs discussed topics related to symptom control, such as the possibility of rebound symptoms, the need to taper PPIs, and what to do if symptoms returned. This aligned with what patients felt was important to discuss. Some GPs routinely incorporated patient preferences into decisions, whereas others did not.

Conclusion

When discussing PPI deprescribing, the GPs in our study generally focused on topics related to symptom control. There was variability in how and if patient preferences were discussed. Greater focus may be needed on developing mechanisms to elicit and incorporate patient preferences into PPI deprescribing decisions. Future research could also explore more systematic approaches to reassess ongoing PPI use in an effort to curb unnecessary long-term use of PPIs.

Peer-Led Education Expedites Deprescribing Proton Pump Inhibitors for Appropriate Veterans

Costly proton pump inhibitors have been widely prescribed since the 1990s for prevention and treatment of ulcers and gastroesophageal reflux disease. Evidence published since 2012 demonstrates risks associated with taking proton pump inhibitors for longer than 8 weeks. Primary care providers mostly deprescribe proton pump inhibitors for persons not meeting criteria for long-term use. Many patients resist discontinuation.A 3-month evidence-based practice education project was conducted by a nurse practitioner to improve primary care provider peer deprescribing successes with appropriate patients in an outpatient California-based veteran primary care clinic. Fifteen primary care providers were pretested about usual care practices between 2 comparable clinics. Five primary care providers at the smaller clinic location were educated about long-term proton pump inhibitor use risks and introduced to 3 evidence-based practice guidelines using tapering techniques with follow-up care.A Canadian 2017 evidence-based practice proton pump inhibitor deprescribing guideline was proposed for translation into practice. Primary care providers voted to pilot this guideline, dependent upon nursing support. Primary care providers denied frustration with usual care practices, even as all were willing to try an evidence-based practice change between pre- and post-test surveys. Support for peer-led evidence-based practice on-site coaching increased from 87% to 100%. Tapering behavior increased from 67% to 100%, expediting improved long-term medication cessation.

Prescription switching: Rationales and risks

BACKGROUND

Therapeutic drug switching is commonplace across a broad range of indications and, within a drug class, is often facilitated by the availability of multiple drugs considered equivalent. Such treatment changes are often considered to improve outcomes via better efficacy or fewer side effects, or to be more cost-effective. Drug switching can be both appropriate and beneficial for several reasons; however, switching can also be associated with negative consequences.

AIM

To consider the impact of switching in two situations: the use of statins as a well-studied example of within-class drug switching, and gonadotropin-releasing hormone (GnRH)-targeting drug switching as an example of cross-class switching.

RESULTS

With the example of statins, within-class switching may be justified to reduce side effects, although the decision to switch is often also driven by the lower cost of generic formulations. With the example of GnRH agonists/antagonists, switching often occurs without the realisation that these drugs belong to different classes, with potential clinical implications.

CONCLUSION

Lessons emerging from these examples will help inform healthcare practitioners who may be considering switching drug prescriptions.

Passing the acid test? Evaluating the impact of national education initiatives to reduce proton pump inhibitor use in Australia

BACKGROUND

Proton pump inhibitor (PPI) use is widespread. There have been increasing concerns about overuse of high-dose PPIs for durations longer than clinically necessary.

OBJECTIVE

To evaluate the impact of national education initiatives on reducing PPI use in Australia.

DESIGN

Population-based, controlled interrupted time series analysis of PPI dispensing claims data for Australian adults from July 2012 to June 2018; we used statin dispensing as a control.

INTERVENTIONS

A year-long educational initiative led by NPS MedicineWise (previously the National Prescribing Service) from April 2015. Simultaneously, Choosing Wisely released recommendations in April 2015 and May 2016. Both promoted review of prolonged PPI use and encouraged stepping down or ceasing treatment, where appropriate.

MEASUREMENTS

We examined monthly changes in PPI (and statin) dispensing (stratified by high, standard and low tablet strength), rates of switching from higher to lower strength PPIs and rates of PPI (and statin) discontinuation.

RESULTS

We observed 12 040 021 PPI dispensings to 579 594 people. We observed a sustained -1.7% (95% CI: -2.7 to -0.7%) decline in monthly dispensing of standard strength PPIs following the initiatives until the end of the study period. There were no significant changes in high or low strength PPI (or statin) dispensings, switching to lower strength PPIs, or PPI (and statin) treatment discontinuation.

CONCLUSION

Our findings suggest that these educational initiatives alone were insufficient in curbing overuse of PPIs on a national level. Concerted efforts with policy levers such as imposing tighter restrictions on subsidised use of PPIs may be more effective. Noting low strength esomeprazole is not publicly subsidised in Australia, availability of these preparations may also facilitate more appropriate practice.

A collaborative intervention for deprescribing: The role of stakeholder and patient engagement

BACKGROUND

At a recent World Café Workshop on future deprescribing priorities, Canadian researchers identified that, in addition to implementation evaluation and economic analyses, high quality clinical trials require meaningful patient engagement.

OBJECTIVES

The aim was to develop a deprescribing intervention for collaborative primary healthcare clinics and long-term care facilities that have pharmacists integrated in these settings. This manuscript aims to provide a summary of the experience with engaging patients in the development of the deprescribing framework.

METHODS

Sixteen members of the research team met with six patient representatives (identified by the Maritime SPOR SUPPORT Unit) in a facilitated meeting. The event provided a welcoming environment for all participants; discussion groups ensured a mix of clinical, research and patient voice; and facilitators focused on engaging all voices equally. Initial discussions were structured around four topics: 1) identifying and prioritizing potentially inappropriate medications to reduce or stop; 2) identifying patients appropriate for deprescribing; 3) effectively communicating deprescribing with both patients and prescribers; and 4) measuring satisfaction with the framework. Subsequent discussions used group input to draft an intervention. After the event, participants engaged via e-mail, to refine the proposed intervention.

RESULTS

The facilitated meeting provided helpful insight into patients' interests and changed the shape of the project. For example, patient representatives felt that an age restriction of 65 years of age or older was unfair, as deprescribing may help people younger than 65 years of age. Patient representatives also felt it was crucial to have resources to offer with non-pharmacologic information to increase success of deprescribing. This led to the deprescribing intervention becoming a framework for pharmacist-led deprescribing and a toolbox of supportive patient and healthcare professional resources.

CONCLUSIONS

Overall, this process allowed for successful and meaningful patient engagement that aligned well with priorities for deprescribing clinical trials.