Regular review of the need for and dosage of proton pump inhibitors such as omeprazole, pantoprazole or esomeprazole is recommended.
If there is no clear indication for long-term PPI use, treatment should be stopped.
Deprescribing PPIs reduces drug costs, reduces the patient's risk of side effects and counteracts polypharmacy.
Proton pump inhibitors such as omeprazole, pantoprazole or esomeprazole are often found on the medication list of patients with heartburn or reflux disease. Not infrequently, the therapy is continued in the long term, although there is no comprehensible reason for the medication. In some cases it is a leftover from a hospital stay or the stomach protection was started some time ago and simply never ended. Whether it makes sense to continue prescribing the medication against acid reflux should be critically questioned on a regular basis. This is because medication not only causes unnecessary health care costs, but can also increase the risk of side effects (e.g. risk of pneumonia in case of overdose). In addition, there is the risk of polypharmacy, which has a stressful effect on patients.
Which patients benefit from stopping the medication? When should PPI use be continued? The study "Clinical Practice Update on De-Prescribing of Proton Pump Inhibitors" by Targownik and colleagues on so-called deprescribing could be helpful for this decision in everyday practice. The team has created a plan for weaning off. This can be groundbreaking. The following advice is given:
In all patients who take proton pump inhibitors such as omeprazole, pantoprazole or esomeprazole on a long-term basis, the indication should be evaluated regularly. This should be done as part of the general practitioner's care. Furthermore, it helps to carefully document the respective reason for taking the medication in order to avoid future ambiguities.
If there is no clear indication for long-term therapy, stopping the medication can be considered.
If there are reasons for long-term stomach protection, the dosage of the active substance should be reviewed. Often, with the same effect, administration of the PPI in the morning and evening, for example, can be reduced to once a day.
For some patient groups, therapy with proton pump inhibitors should be maintained. These include patients with erosive oesophagitis, oesophageal ulcer, peptic stricture, Barrett's oesophagus, eosinophilic oesophagitis or idiopathic pulmonary fibrosis.
Stratification of the risk of upper gastrointestinal bleeding must be performed before the decision to discontinue PPIs is made. If the risk is high, the drug should continue to be taken.
Discontinuation of continuous PPI therapy may cause temporary discomfort due to reactive excessive secretion of gastric acid. It is important to make people aware of this rebound effect.
If the decision is made to discontinue proton pump inhibitors, the substances can either be phased out or the intake can be stopped abruptly.
In general, the decision to discontinue PPI therapy should only be based on the absence of an indication. Concern about drug-induced side effects, even if already known anamnestically, is not a sufficient reason for discontinuing acid blockers.
Deprescribing proton pump inhibitors is not straightforward. Even though many factors have to be taken into account, the necessity of the treatment should be reconsidered regularly. This will save patients from a possibly unnecessary therapy that may also be accompanied by side effects. The tips mentioned can be helpful here and facilitate the daily routine of a GP.
Targownik LE, Fisher DA, Saini SD. AGA Clinical Practice Update on De-Prescribing of Proton Pump Inhibitors: Expert Review. Gastroenterology. 2022 Apr;162(4):1334-1342. doi: 10.1053/j.gastro.2021.12.247. Epub 2022 Feb 17. PMID: 35183361.