1
|
Rossi A, Perrella L, Scotti S, Olmastroni E, Galimberti F, Ardoino I, Orlando V, Menditto E, Franchi C, Casula M. Approaches to Deprescribing Proton Pump Inhibitors in Clinical Practice: A Systematic Review. J Clin Med 2024; 13:6283. [PMID: 39458232 PMCID: PMC11508458 DOI: 10.3390/jcm13206283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2024] [Revised: 10/06/2024] [Accepted: 10/15/2024] [Indexed: 10/28/2024] Open
Abstract
Background: Proton pump inhibitors (PPIs) are some of the most frequently prescribed medications, but they are often used inappropriately, either being prescribed without a clear indication or continued for longer than necessary. In such cases, deprescribing is recommended. However, despite its proven effectiveness, the implementation of deprescribing in clinical practice remains inconsistent and varied, making it challenging to identify the most effective strategies. The goal is to provide a comprehensive outline of deprescribing interventions for PPI therapy implemented across various settings and by different healthcare professionals. Methods: The study is designed to be a systematic review of the published literature. PubMed, Embase, and Web of Science databases were searched from 1 January 1989 (the first PPI on the market) to 30 September 2024 for articles assessing PPI deprescribing in adult patients, focusing on the implementation rate (primary outcome) or effects on symptoms (secondary outcome). Results: After screening, 66 studies were included, predominantly pragmatic trials (N = 32) or randomized controlled trials (N = 25). We found a variety of interventions promoting PPI deprescription. Collaborative efforts involving multiple healthcare professionals, the use of algorithms for clinical decision-making, and patient involvement have proven to be key elements in the most effective strategies. Discontinuing therapy may not be advisable in cases of recurrent symptoms, suggesting that on-demand therapy could be a recommended approach. Deprescribing is particularly relevant for individuals with mild illnesses and symptoms, where tapering can effectively mitigate the rebound symptoms often associated with abrupt discontinuation. Conclusions: Given the current prevalence of inappropriate PPI prescribing, it is imperative to raise awareness among both physicians and patients about the importance of the deprescribing process, which should be tailored to the specific needs of each patient, considering his/her medical history, current health status, and personal preferences.
Collapse
Affiliation(s)
- Andrea Rossi
- Epidemiology and Preventive Pharmacology Service (SEFAP), Department of Pharmacological and Biomolecular Sciences (DiSFeB), University of Milan, 20133 Milan, Italy; (A.R.); (E.O.)
- IRCCS MultiMedica, 20099 Sesto San Giovanni, Italy; (S.S.); (F.G.)
| | - Lara Perrella
- Center of Pharmacoeconomics and Drug Utilization Research (CIRFF), Department of Pharmacy, University of Naples Federico II, 80138 Naples, Italy; (L.P.); (V.O.); (E.M.)
| | - Stefano Scotti
- IRCCS MultiMedica, 20099 Sesto San Giovanni, Italy; (S.S.); (F.G.)
| | - Elena Olmastroni
- Epidemiology and Preventive Pharmacology Service (SEFAP), Department of Pharmacological and Biomolecular Sciences (DiSFeB), University of Milan, 20133 Milan, Italy; (A.R.); (E.O.)
- IRCCS MultiMedica, 20099 Sesto San Giovanni, Italy; (S.S.); (F.G.)
| | | | - Ilaria Ardoino
- Laboratory of Pharmacoepidemiology and Human Nutrition, Department of Health Policy, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 20156 Milan, Italy; (I.A.); (C.F.)
| | - Valentina Orlando
- Center of Pharmacoeconomics and Drug Utilization Research (CIRFF), Department of Pharmacy, University of Naples Federico II, 80138 Naples, Italy; (L.P.); (V.O.); (E.M.)
| | - Enrica Menditto
- Center of Pharmacoeconomics and Drug Utilization Research (CIRFF), Department of Pharmacy, University of Naples Federico II, 80138 Naples, Italy; (L.P.); (V.O.); (E.M.)
| | - Carlotta Franchi
- Laboratory of Pharmacoepidemiology and Human Nutrition, Department of Health Policy, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 20156 Milan, Italy; (I.A.); (C.F.)
| | - Manuela Casula
- Epidemiology and Preventive Pharmacology Service (SEFAP), Department of Pharmacological and Biomolecular Sciences (DiSFeB), University of Milan, 20133 Milan, Italy; (A.R.); (E.O.)
- IRCCS MultiMedica, 20099 Sesto San Giovanni, Italy; (S.S.); (F.G.)
| |
Collapse
|
2
|
Almadi MA, Lu Y, Alali AA, Barkun AN. Peptic ulcer disease. Lancet 2024; 404:68-81. [PMID: 38885678 DOI: 10.1016/s0140-6736(24)00155-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 09/22/2023] [Accepted: 01/24/2024] [Indexed: 06/20/2024]
Abstract
Annual prevalence estimates of peptic ulcer disease range between 0·12% and 1·5%. Peptic ulcer disease is usually attributable to Helicobacter pylori infection, intake of some medications (such as aspirin and non-steroidal anti-inflammatory medications), or being critically ill (stress-related), or it can be idiopathic. The clinical presentation is usually uncomplicated, with peptic ulcer disease management based on eradicating H pylori if present, the use of acid-suppressing medications-most often proton pump inhibitors (PPIs)-or addressing complications, such as with early endoscopy and high-dose PPIs for peptic ulcer bleeding. Special considerations apply to patients on antiplatelet and antithrombotic agents. H pylori treatment has evolved, with the choice of regimen dictated by local antibiotic resistance patterns. Indications for primary and secondary prophylaxis vary across societies; most suggest PPIs for patients at highest risk of developing a peptic ulcer, its complications, or its recurrence. Additional research areas include the use of potassium-competitive acid blockers and H pylori vaccination; the optimal approach for patients at risk of stress ulcer bleeding requires more robust determinations of optimal patient selection and treatment selection, if any. Appropriate continuation of PPI use outweighs most possible side-effects if given for approved indications, while de-prescribing should be trialled when a definitive indication is no longer present.
Collapse
Affiliation(s)
- Majid A Almadi
- Division of Gastroenterology, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia; Division of Gastroenterology, The McGill University Health Center, Montréal General Hospital, McGill University, Montréal, QC, Canada
| | - Yidan Lu
- Division of Gastroenterology, The McGill University Health Center, Montréal General Hospital, McGill University, Montréal, QC, Canada
| | - Ali A Alali
- Department of Medicine, Faculty of Medicine, Kuwait University, Jabriyah, Kuwait
| | - Alan N Barkun
- Division of Gastroenterology, The McGill University Health Center, Montréal General Hospital, McGill University, Montréal, QC, Canada; Division of Clinical Epidemiology, The McGill University Health Center, Montréal General Hospital, McGill University, Montréal, QC, Canada.
| |
Collapse
|
3
|
Rodrigues DA, Herdeiro MT, Mateos-Campos R, Figueiras A, Roque F. Magnitude and Determinants of Long-term Use of Proton Pump Inhibitors Among Portuguese Older Adults in Primary Health Care. Clin Ther 2024; 46:e54-e58. [PMID: 38061931 DOI: 10.1016/j.clinthera.2023.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 11/14/2023] [Accepted: 11/14/2023] [Indexed: 02/27/2024]
Abstract
PURPOSE Proton Pump Inhibitors (PPIs) have been associated with several adverse effects of particular concern in older populations. Their use for a period longer than 8 weeks is not recommended for older adults. Strategies to discontinue PPIs have been offered; however, their use remains high. This study aims to characterize PPI use in Portuguese older people and to identify the factors associated with potentially inappropriate use. METHODS A cross-sectional study was conducted on 1200 randomly selected older adults (≥65 years of age), users of primary health care facilities in the Regional Health Administration (Administração Regional de Saúde of Centro [ARSC]) of Portugal between April 2021 and August 2022. Data concerning their characteristics and PPI use were provided by the Shared Services of the Health Ministry (Serviços Partilhados do Ministério da Saúde) and collected retrospectively. Associations between independent variables and PPI use were investigated by logistic regression analysis. FINDINGS Of the older adults, 37.92% were receiving PPIs and 78.68% of them were taking them for a longer period than recommended; 49.79% were taking PPIs without having any digestive system-related disease. Multivariate analysis showed that the prolonged use of PPIs was not associated with any specific pattern, although inappropriate PPI use is high among Portuguese older adults. IMPLICATIONS Long-term PPI use in older adults is widespread and does not fit any particular patient profile; therefore, cross-cutting educational interventions should be designed independently of the patient's pathologic condition or treatment.
Collapse
Affiliation(s)
- Daniela A Rodrigues
- Research Laboratory on Epidemiology and Population Health, Polytechnic of Guarda (IPG), 6300-559, Guarda, Portugal; Health Sciences Research Centre, University of Beira Interior (CICS-UBI), 6200-506, Covilhã, Portugal; PhD Student, University of Salamanca, 37007, Salamanca, Spain
| | - Maria Teresa Herdeiro
- Department of Medical Sciences, Institute of Biomedicine (iBiMED), University of Aveiro, 3810-193, Aveiro, Portugal
| | - Ramona Mateos-Campos
- Area of Preventive Medicine and Public Health, Department of Biomedical and Diagnostic Sciences, University of Salamanca, 37007, Salamanca, Spain
| | - Adolfo Figueiras
- Department of Preventive Medicine and Public Health, University of Santiago de Compostela, 15702, Santiago de Compostela, Spain; Health Research Institute of Santiago de Compostela (IDIS), 15706, Santiago de Compostela, Spain; Consortium for Biomedical Research in Epidemiology and Public Health (CIBER Epidemiology and Public Health-CIBERESP), 28001, Madrid, Spain
| | - Fátima Roque
- Research Laboratory on Epidemiology and Population Health, Polytechnic of Guarda (IPG), 6300-559, Guarda, Portugal; Health Sciences Research Centre, University of Beira Interior (CICS-UBI), 6200-506, Covilhã, Portugal.
| |
Collapse
|
4
|
Plehhova K, Häring M, Wray J, Coyle C, Kostev K. Proton Pump Inhibitors in Germany: Status Quo of a Growing Market. Health Serv Res Manag Epidemiol 2024; 11:23333928241241220. [PMID: 38562150 PMCID: PMC10983788 DOI: 10.1177/23333928241241220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 02/12/2024] [Accepted: 03/05/2024] [Indexed: 04/04/2024] Open
Abstract
Introduction The volume of prescriptions for proton pump inhibitors (PPIs) remains high, although the literature increasingly points to excessive prescribing in relation to guideline recommendations. No very recent data is available on the specific situation in Germany, particularly on the proportion of PPI consumption from over-the-counter (OTC) sales and self-selection, following PPI down-scheduling. The aim of this study was to determine the actual amount of prescribed and OTC PPIs in Germany. Methods For this retrospective study, several IQVIA databases were used, representing all prescriptions billed to statutory and private health insurers in Germany, as well as OTC sales. Analyses were performed for the period November 2020 to October 2021 or partially November 2018 to October 2021 and were descriptive in nature. Mainly, data were collected from IQVIATM PharmaScope National® as well as IQVIA TM DPM® databases. Results A total of 2.87 billion PPI tablets were shown to have been sold between November 2020 and October 2021, with most drugs prescribed in the largest packages and strengths. In addition, the OTC PPI market increased by an average of 14% per year over a 3-year period. Conclusions The results of this study suggest the substantial size of the PPI market in Germany is based on prescriptions, a consistent increase in OTC PPI purchases and a recent increase in prescriptions.
Collapse
|
5
|
Ando T, Sasaki T, Abe Y, Nishimoto Y, Hirata T, Haruta J, Arai Y. Measurement of polydoctoring as a crucial component of fragmentation of care among patients with multimorbidity: Cross-sectional study in Japan. J Gen Fam Med 2023; 24:343-349. [PMID: 38025930 PMCID: PMC10646296 DOI: 10.1002/jgf2.651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 09/03/2023] [Accepted: 09/11/2023] [Indexed: 12/01/2023] Open
Abstract
Background Care fragmentation, characterized by the uncoordinated involvement of multiple healthcare providers, leads to inefficient and ineffective healthcare, posing a significant challenge in managing patients with multimorbidity. In this context, "polydoctoring," where patients see multiple specialists, emerges as a crucial aspect of care fragmentation. This study seeks to develop an indicator to assess polydoctoring, which can subsequently enhance the management of multimorbidity. Methods Baseline survey data from the Kawasaki Aging and Wellbeing Project (KAWP) involving independent community-dwelling older adults aged 85-89 were utilized in this cross-sectional study. Polydoctoring measure was defined as the number of regularly visited facilities (RVFs). The association of RVF with the Fragmentation of Care Index (FCI) and the outcome measures of polypharmacy and ambulatory care costs were examined as indicators of care fragmentation. Results The analysis comprised 968 participants, with an average of 4.70 comorbid chronic conditions; 65.3% of the participants had two or more RVFs, indicating polydoctoring. A significant correlation between RVF and FCI was observed. Modified Poisson regression analyses revealed associations between higher RVF and increased prevalence ratio of polypharmacy. Likewise, a higher RVF was associated with higher outpatient medical costs. Conclusions RVF was significantly correlated with FCI, polypharmacy, and higher outpatient medical costs. Unlike complex indices, RVF is simple and intuitively comprehensible. Further research is needed to evaluate the impact of care fragmentation on patient outcomes, considering factors such as RVF thresholds, patient multimorbidity, and social support. Understanding the influence of polydoctoring can enhance care quality and efficiency for patients with multimorbidity.
Collapse
Affiliation(s)
- Takayuki Ando
- Center for General Medicine EducationKeio University School of MedicineTokyoJapan
| | - Takashi Sasaki
- Center for Supercentenarian Medical ResearchKeio University School of MedicineTokyoJapan
| | - Yukiko Abe
- Center for Supercentenarian Medical ResearchKeio University School of MedicineTokyoJapan
| | - Yoshinori Nishimoto
- Center for Supercentenarian Medical ResearchKeio University School of MedicineTokyoJapan
- Department of NeurologyKeio University School of MedicineTokyoJapan
| | - Takumi Hirata
- Center for Supercentenarian Medical ResearchKeio University School of MedicineTokyoJapan
- Institute for Clinical and Translational ScienceNara Medical UniversityKashiharaJapan
| | - Junji Haruta
- Center for General Medicine EducationKeio University School of MedicineTokyoJapan
- Medical Education CenterKeio University School of MedicineTokyoJapan
| | - Yasumichi Arai
- Center for Supercentenarian Medical ResearchKeio University School of MedicineTokyoJapan
| |
Collapse
|
6
|
Baiardi G, Calvini G, Panarello S, Fioravanti C, Stella M, Martelli A, Antonucci G, Mattioli F. Prescriptive Appropriateness: Inhospital Adherence to Proton Pump Inhibitors Deprescription Flow Chart. Pharmaceuticals (Basel) 2023; 16:ph16050635. [PMID: 37242418 DOI: 10.3390/ph16050635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 04/13/2023] [Accepted: 04/20/2023] [Indexed: 05/28/2023] Open
Abstract
The prescriptive appropriateness of Proton Pump Inhibitors (PPIs) in polypharmacy is controversial. PPIs are often overprescribed and the risk of prescribing errors and adverse drug reactions increases for each additional drug added to therapy. Hence, guided deprescription should be considered and easily implementable in ward practice. This observational prospective study evaluated the implementation of a validated PPIs deprescription flow chart to real-life internal ward activity through the presence of a clinical pharmacologist as an enhancing additional factor by assessment of inhospital prescriber's adherence to the proposed flow chart. Patients' demographics and prescribing trends of PPIs prescriptions were analyzed by descriptive statistics. The final analysis of data included ninety-eight patients (forty-nine male and forty-nine female), aging 75.6 ± 10.6 years; 55.1% of patients had home-PPIs prescriptions, while 44.9% received inhospital-PPIs prescriptions. Evaluation of prescriber's adherence to the flow chart revealed that the percentage of patients with a prescriptive/deprescriptive pathway conforming to that of the flow chart was 70.4%, with low symptomatologic recurrences. The clinical pharmacologists' presence and influence in ward activity may have contributed to this finding, since continuous training of the prescribing physicians is deemed a success-related factor in the deprescribing strategy. Multidisciplinary management of PPIs deprescription protocols shows high adherence by prescribers in real-life hospital settings and low recurrence events.
Collapse
Affiliation(s)
- Giammarco Baiardi
- Clinical Pharmacology Unit, E.O. Ospedali Galliera, Mura delle Cappuccine 14, 16128 Genoa, Italy
- Pharmacology and Toxicology Unit, Department of Internal Medicine, University of Genoa, Viale Benedetto XV 2, 16132 Genoa, Italy
| | - Giulia Calvini
- Clinical Pharmacology Unit, E.O. Ospedali Galliera, Mura delle Cappuccine 14, 16128 Genoa, Italy
- Pharmacology and Toxicology Unit, Department of Internal Medicine, University of Genoa, Viale Benedetto XV 2, 16132 Genoa, Italy
| | - Serena Panarello
- Internal Medicine Unit, E.O. Ospedali Galliera, Mura delle Cappuccine 14, 16128 Genoa, Italy
| | - Chiara Fioravanti
- Internal Medicine Unit, E.O. Ospedali Galliera, Mura delle Cappuccine 14, 16128 Genoa, Italy
| | - Manuela Stella
- Clinical Pharmacology Unit, E.O. Ospedali Galliera, Mura delle Cappuccine 14, 16128 Genoa, Italy
- Pharmacology and Toxicology Unit, Department of Internal Medicine, University of Genoa, Viale Benedetto XV 2, 16132 Genoa, Italy
| | - Antonietta Martelli
- Pharmacology and Toxicology Unit, Department of Internal Medicine, University of Genoa, Viale Benedetto XV 2, 16132 Genoa, Italy
| | - Giancarlo Antonucci
- Internal Medicine Unit, E.O. Ospedali Galliera, Mura delle Cappuccine 14, 16128 Genoa, Italy
| | - Francesca Mattioli
- Clinical Pharmacology Unit, E.O. Ospedali Galliera, Mura delle Cappuccine 14, 16128 Genoa, Italy
- Pharmacology and Toxicology Unit, Department of Internal Medicine, University of Genoa, Viale Benedetto XV 2, 16132 Genoa, Italy
| |
Collapse
|