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Mati E, Mioux L, Ollagnier G, Waissi A, Benzerdjeb N, Messaoudi K, De La Gastine B, Aouni F, Ahmine S, Leperre A, Bleyzac N. How could proton pump inhibitors de-prescription be managed in geriatric long-term care? Therapie 2024:S0040-5957(24)00064-7. [PMID: 38908995 DOI: 10.1016/j.therap.2024.05.002] [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: 03/28/2023] [Revised: 04/11/2024] [Accepted: 05/13/2024] [Indexed: 06/24/2024]
Abstract
BACKGROUND Evaluate the misuse of proton pump inhibitors (PPIs) in geriatric long-term care (LTC) patients and improve caregiving by de-prescribing non-relevant PPIs in this population. AIM This study was conducted in the long-term care department of the geriatric hospital Pierre-Garraud in Lyon. All patients receiving PPI for more than 8 weeks were included. A reassessment form was filled to evaluate the treatment benefit/risk ratio during a collegial consultation between the patient's referring physicians and pharmacists. During these consultations, the following possible decisions were taken: continuation, dose adjustment or gradual discontinuation of treatment. Patients' monitoring were performed one month and three months after discontinuation to detect any relapses and causes. RESULTS Among the 113 patients included, 97 patients had their treatment re-evaluated by collegial consultation. Forty-four (45.4%) patients were treated in accordance with recommendations. For 24 of them, the indication was symptomatic recurrent gastroesophageal reflux disease. The treatment of more than half of the re-evaluated patients (54.6%) was gradually stopped. After the 3-month follow-up post-discontinuation, excluding patients who died during this period, 80.9% of the discontinuations were well-tolerated and only nine were resumed (19.1%). CONCLUSION This study allowed a re-evaluation of PPI treatments in a high-risk population and offered a decision support tool focused on the benefit/risk balance of PPIs; 55% of treatments were considered irrelevant and could be stopped with 80% of good tolerance.
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Affiliation(s)
- Elma Mati
- Hôpital Pierre-Garraud, hospices civils de Lyon, 69000 Lyon, France
| | - Lisa Mioux
- Hôpital Pierre-Garraud, hospices civils de Lyon, 69000 Lyon, France
| | - Grégoire Ollagnier
- Geriatric long-term care medicine, hôpital Pierre-Garraud, hospices civils de Lyon, 69000 Lyon, France
| | - Aziza Waissi
- Geriatric long-term care medicine, hôpital Pierre-Garraud, hospices civils de Lyon, 69000 Lyon, France
| | - Nacera Benzerdjeb
- Geriatric long-term care medicine, hôpital Pierre-Garraud, hospices civils de Lyon, 69000 Lyon, France
| | - Karima Messaoudi
- Geriatric long-term care medicine, hôpital Pierre-Garraud, hospices civils de Lyon, 69000 Lyon, France
| | - Blandine De La Gastine
- Geriatric long-term care medicine, hôpital Pierre-Garraud, hospices civils de Lyon, 69000 Lyon, France
| | - Fayçal Aouni
- Geriatric long-term care medicine, hôpital Pierre-Garraud, hospices civils de Lyon, 69000 Lyon, France
| | - Sabiha Ahmine
- Geriatric long-term care medicine, hôpital Pierre-Garraud, hospices civils de Lyon, 69000 Lyon, France
| | - Armelle Leperre
- Geriatric long-term care medicine, hôpital Pierre-Garraud, hospices civils de Lyon, 69000 Lyon, France
| | - Nathalie Bleyzac
- Pharmacy department, hôpital Pierre-Garraud, hospices civils de Lyon, 69000 Lyon, France.
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Leszcynski L, Bente J. Development and Implementation of a Pharmacist-Led Proton Pump Inhibitor Deprescribing Algorithm in a Geriatric Ambulatory Office. Sr Care Pharm 2023; 38:105-112. [PMID: 36803698 DOI: 10.4140/tcp.n.2023.105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
Background The American Geriatrics Society 2019 Updated Beers Criteria© recommends avoiding scheduled use of proton pump inhibitors (PPIs) for greater than eight weeks in older people because of potential risk of bone loss and fractures and Clostridioides difficile infection. There are limited studies evaluating the effectiveness of deprescribing PPIs in this patient population. Objective The purpose of this study was to evaluate the implementation of a PPI deprescribing algorithm in a geriatric ambulatory office on the appropriateness of PPI use in older people. Methods This single-center study evaluated PPI use in a geriatric ambulatory office pre- and post-implementation of a deprescribing algorithm. Participants included all patients 65 years of age or older and a documented PPI on their home medication list. The PPI deprescribing algorithm was developed by the pharmacist using components of the published guideline. The primary outcome was the percentage of patients on a PPI with a potentially inappropriate indication before and after implementation of this deprescribing algorithm. Results At baseline, 228 patients were treated with a PPI, and 64.5% (n = 147) of patients were treated for a potentially inappropriate indication. Of the 228 patients, 147 patients were included in the primary analysis. Potentially inappropriate use of PPI significantly decreased after implementation of a deprescribing algorithm from 83.7% to 44.2% in the cohort of patients who were eligible for deprescribing (difference 39.5%; P < 0.0001). Conclusion Potentially inappropriate PPI use in older adults decreased after implementation of a pharmacist-led deprescribing initiative, supporting the role of pharmacists on interdisciplinary deprescribing teams.
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Affiliation(s)
| | - Jessica Bente
- Cooperman Barnabas Medical Center, Livingston, New Jersey
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Toth JM, Jadhav S, Holmes HM, Sharma M. Prescribing trends of proton pump inhibitors, antipsychotics and benzodiazepines of medicare part d providers. BMC Geriatr 2022; 22:306. [PMID: 35395728 PMCID: PMC8993456 DOI: 10.1186/s12877-022-02971-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 03/22/2022] [Indexed: 11/21/2022] Open
Abstract
Background Proton pump inhibitors, benzodiazepines, and antipsychotics are considered potentially inappropriate medications in older adults according to the American Geriatric Society Beers Criteria, and deprescribing algorithms have been developed to guide use of these drug classes. The objective of this study was to describe the number of beneficiaries prescribed these medications, provider specialty and regional trends in prescribing, and the aggregate costs for these claims in Medicare Part D. Methods This was a retrospective cross-sectional study using publicly available Medicare Provider Utilization and Payment Data: Part D Prescriber data for years 2013–2019. Descriptive statistics and the Cochrane-Armitage test were used to summarize the trends. Results Overall, 30.1%, 25.6%, 4.6% of Medicare Part D beneficiaries had a proton pump inhibitor, benzodiazepine, and antipsychotic claim in 2013, respectively. These rates decreased to 27.5%, 17.5%, 4.1% in 2019 (p-value < 0.0001). However, the number of standardized 30-day claims increased from 63 million in 2013 to 84 million in 2019 for proton pump inhibitors, remained steady for benzodiazepines and slightly increased (10 million to 13 million) for antipsychotics. Total aggregate costs decreased by almost $1.5 billion for proton pump inhibitor, $100 million for benzodiazepine, and $700 million for antipsychotic from 2013 to 2019 (p-value < 0.0001). Almost 93% of gastroenterologists prescribed a proton pump inhibitor, and 60% of psychiatrists prescribed benzodiazepines and antipsychotics all seven years. The Other region had the highest percentage of providers prescribing all three classes and the highest number of standardized 30-day benzodiazepine claims. Conclusions The overall rate of use of proton pump inhibitors, benzodiazepines, and antipsychotics decreased from 2013–2019 among Medicare Part D beneficiaries. Despite the increase in raw number of standardized 30-day claims, the costs decreased which is likely due to generics made available. These prescribing trends may aid in identifying and targeting potential deprescribing interventions.
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Affiliation(s)
- Jennifer M Toth
- Department of Pharmacy Administration, The University of Mississippi, University, MS, 38677, USA.
| | - Saumil Jadhav
- Department of Pharmacy Administration, The University of Mississippi, University, MS, 38677, USA
| | - Holly M Holmes
- Division of Geriatric and Palliative Medicine, McGovern Medical School, The University of Texas Health Science Center, Houston, TX, USA
| | - Manvi Sharma
- Department of Pharmacy Administration, The University of Mississippi, University, MS, 38677, USA
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Ayoub J, McGregor JC, Castner RM, Singh H. Opportunities for successful de-escalation of proton pump inhibitors at a federally qualified health center. BMC Pharmacol Toxicol 2021; 22:20. [PMID: 33863393 PMCID: PMC8052786 DOI: 10.1186/s40360-021-00486-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 03/29/2021] [Indexed: 11/18/2022] Open
Abstract
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.
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Affiliation(s)
- Joelle Ayoub
- Western University of Health Sciences College of Pharmacy, 309 E. Second St., Pomona, 91766, CA, USA.
| | - Jessina C McGregor
- Oregon State University College of Pharmacy Portland Campus at Oregon Health & Science University, 2730 SW Moody Ave., CL5CP, Portland, 97239, OR, USA
| | - Rebecca M Castner
- Roosevelt University College of Pharmacy, 1400 N Roosevelt Blvd, Schaumburg, 60173, IL, USA
| | - Harleen Singh
- Oregon State University College of Pharmacy Portland Campus at Oregon Health & Science University, 2730 SW Moody Ave., CL5CP, Portland, 97239, OR, USA
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Ikeji C, Williams A, Hennawi G, Brandt NJ. Patient and Provider Perspectives on Deprescribing Proton Pump Inhibitors. J Gerontol Nurs 2020; 45:9-17. [PMID: 31560071 DOI: 10.3928/00989134-20190912-03] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The aim of the current study is to describe proton pump inhibitor (PPI) prescribing trends in an older adult population and elucidate perspectives regarding PPI deprescribing. A retrospective chart review and a prospective cross-sectional analysis of provider and patient surveys were conducted. The retrospective chart review identified 107 patients age ≥65 who were prescribed PPI therapy. Nineteen patients on PPI therapy and 74 providers completed surveys regarding their perspectives on PPI deprescribing. PPI therapy was potentially inappropriate for 66% of patients based on dose, duration, and/or indication. Provider barriers to deprescribing included fear of outcomes, access to documentation, and uncertainty of current guidelines. This study illustrates the prevalence of long-term PPI use in geriatric patients without associated clinical indications, as well as perceived barriers to deprescribing. Long-term PPI use is associated with significant side effects; therefore, successful deprescribing must address these perceived barriers. [Journal of Gerontological Nursing, 45(10), 9-17.].
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Abstract
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.
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Walker MJ, Crews NR, El-Halabi M, Fayad NF. Educational Intervention Improves Proton Pump Inhibitor Stewardship in Outpatient Gastroenterology Clinics. Gastroenterology Res 2019; 12:305-311. [PMID: 31803310 PMCID: PMC6879027 DOI: 10.14740/gr1238] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 11/05/2019] [Indexed: 12/12/2022] Open
Abstract
Background Improper chronic proton pump inhibitor (PPI) use has risen significantly in the last few decades. In our gastroenterology trainees’ clinics, we aimed to optimize PPI usage. Methods We collected baseline data on patients’ PPI use for 8 weeks. Based on gastroenterology society guidelines, we determined conditions for appropriate PPI use. If the indication could not be determined, it was categorized as “unknown”. Generated from the three most frequent causes for inappropriate PPI use, interventions were developed to correct each issue. Following a brief educational session, trainees implemented these interventions over a subsequent 8-week interval. Results During our pre-intervention period, trainees evaluated 263 patients who were prescribed a PPI. In 49% of the cases, the use of PPI was deemed inappropriate. The most common reasons were: gastroesophageal reflux disease (GERD) which was never titrated to the lowest effective dose, twice daily dosing for Barrett’s esophagus (BE) chemoprevention and unknown indication. During our intervention period, trainees evaluated 145 patients prescribed a PPI for GERD with well-controlled symptoms in 101 cases. PPI had not been titrated to lowest effective dose in 37 cases prompting intervention which was successful in 23 cases. PPI indication was unknown in 17 cases prompting a message to the prescribing provider to review appropriateness. Two cases of BE chemoprevention with twice daily dosing were appropriately reduced to daily dosing. Ultimately, after intervention, PPI use was deemed appropriate after intervention in 172 (77%) cases. Conclusions Improper chronic PPI use was significant. Focusing intervention efforts on PPI use for GERD, BE and unknown indications substantially increased appropriateness of PPI use.
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Affiliation(s)
- Megan J Walker
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 702 Rotary Circle, Suite 225, Indianapolis, IN 46202, USA
| | - Nicholas R Crews
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 702 Rotary Circle, Suite 225, Indianapolis, IN 46202, USA
| | - Mustapha El-Halabi
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 702 Rotary Circle, Suite 225, Indianapolis, IN 46202, USA
| | - Nabil F Fayad
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, 702 Rotary Circle, Suite 225, Indianapolis, IN 46202, USA
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