AGA Publishes Guidance on PPI De-Prescribing

The American Gastroenterological Association (AGA) has released a clinical practice update to guide de-prescribing of proton pump inhibitors (PPIs), which are among the most used medications worldwide. The update comes on the heels of an increasing body of evidence associating these agents with various risks, particularly upon prolonged use, from an increased susceptibility to infection—such as community-acquired pneumonia and COVID-19 infection—to an increased risk of chronic diseases—such as osteoporosis, dementia, heart disease, and gastric cancer.

The Guiding Principle

“Our 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,” write Laura E. Targownik, MD, and colleagues.

Although PPIs are essential in managing upper gastrointestinal (GI) disorders, studies have suggested these agents are prescribed without an indication in up to 89% of cases. Additionally, many patients self-prescribe over-the-counter PPIs, which may be associated with additional risks, especially when use is not consistent with label instructions.

“Prescribers are responsible for determining whether PPI use is absolutely or conditionally indicated and, when uncertainty exists, to incorporate patient perspectives into PPI decision making,” the authors stated.

The AGA’s update provides a high-level “process map” of the conceptual approach to de-prescribing PPIs in a clinical setting, focusing on 3 key areas: (1) documentation of PPI indication; (2) identifying suitable candidates for consideration of deprescribing; and (3) optimizing successful deprescribing. Because the panel did not conduct a systematic review, the recommendations are not given quality of evidence ratings.

Best Practices for PPI De-Prescribing

The update provides 10 best practice advice statements:

  1. Patients’ primary care physician should regularly review whether their patients on PPIs have appropriate indications for use and document those indications.
  2. Patients without a definitive indication for chronic PPI use should be considered for a trial of deprescribing.
  3. Patients with an appropriate indication for PPI use who are on twice-daily dosing should be considered for step down to once-daily PPI use whenever possible.
  4. Patients with complicated gastroesophageal reflux disease (eg, severe erosive esophagitis, esophageal ulcer, peptic stricture) are generally not considered candidates for PPI discontinuation.
  5. Patients with known Barrett’s esophagus, eosinophilic esophagitis, or idiopathic pulmonary fibrosis are generally not considered candidates for a trial of deprescribing.
  6. Before deprescribing PPIs, patients should be assessed for upper GI bleeding risk using an evidence-based strategy.
  7. Patients at high risk for upper gastrointestinal bleeding are not considered candidates for PPI deprescribing.
  8. Patients who discontinue long-term PPI therapy should be informed of their risk of transient upper gastrointestinal symptoms because of rebound acid hypersecretion.
  9. Deprescribing PPIs can be achieved with either dose tapering or an abrupt discontinuation.
  10. Decision-making regarding PPI discontinuation is based solely on the lack of an indication for PPI use, and not because of concern for PPI-associated adverse events (PAAE). None of the following should be considered independent indications for PPI withdrawal: a current PAAE, a history of PAAE in a current PPI user, or the presence of an underlying risk factor for a PAAE.

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