A lot of my patients take proton pump inhibitors (PPIs). They generally work pretty well for their intended use. By limiting the secretion of gastric acid from the stomach, they can effectively blunt uncomfortable symptoms of erosive gastritis, gastroesophageal reflux disease, H. pylori infection, and peptic ulcers. However, without further evaluation, these medications are not designed to be prescribed indefinitely, or for more than a two-month period. When patients experience relief from a relatively benign medication, it is easy to continue prescribing refills. One click of a button on the electronic health record can send three more months’ worth of pills to the pharmacy. While PPIs like omeprazole (Prilosec) and esomeprazole (Nexium) are not controlled substances with a threat of addiction, patients can become reliant on them on a daily basis for years without adequate follow-up.
How does this snowball effect initiate, especially among elderly populations? A 2021 retrospective cohort study from New York Presbyterian Columbia University Medical Center reviewed the prescribing of PPIs in nine affiliated ICUs. More than one-quarter of patients downgraded to the medical floor were ultimately discharged on a PPI without a long-term indication for therapy. On the outpatient side, a significant portion of patients continue to be prescribed refills without follow-up and evaluation. When surveyed, providers have reported a lack of certainty on formal guidelines as a deterrent to deprescribing for patients on long-term PPI therapy. Lack of access to prior medical records can also obfuscate the original clinical picture of why a patient was started on the medication.
It is important to monitor patients with continuous PPI use as these medications have associated risks. Longer duration of PPI treatment has been associated with a potential increase in gastric and esophageal cancer. PPIs have also been linked to higher rates of pneumonia, C. difficile infection, pathologic fractures, drug-drug interactions, acute interstitial nephritis, progression of chronic kidney disease, and electrolyte disturbances. A fair amount of this data can likely be attributed to confounding factors; however, the overarching guideline remains that patients should be treated with the lowest dose of a PPI for the shortest duration possible. This, if nothing else, limits the risk of polypharmacy.
A quality improvement initiative at our Chicago clinic found that the majority of our patients on PPI therapy last year were treated for more than three months, and less than one third of those patients had been referred to gastroenterology for further workup of refractory symptoms. After a resident and faculty lecture that included the current prescribing guidelines, reminders were posted throughout the clinic for physicians to deprescribe PPIs for patients whose symptoms resolved after a four- to eight-week course by either decreasing to a lower dose as tolerated or discontinuing medication. Subsequent retrospective review showed a reduction of 11 percent in the rate of long-term prescribing. For those requiring additional refills, 43 percent more had been contacted by staff to initiate follow-up evaluation. If they did not already have an established indication for continuous PPI use, these patients were counseled on the risks and benefits and the goal to either deprescribe as tolerated or refer to gastroenterology. These patients either stand to benefit from PPI therapy on an as-needed basis or have further workup, which can include an EGD, impedance pH testing, and esophageal manometry. This is important as PPI use can mask the symptoms of early-stage disease, and other interventions may provide more effective relief than continuous PPI therapy. The aforementioned testing can help identify patients who would benefit from H2 receptor antagonists, reflux inhibitors, prokinetic agents, anti-reflux surgery, or endoscopic interventions. Follow-up appointments are also beneficial to assess compliance with medication and any new changes in symptoms. Concerns for bleeding, anemia, weight loss, and vomiting are red flags necessitating more expedited endoscopy.
There are certainly indications for patients to remain on PPIs for extended periods of time once a clearer diagnosis is reached. Patients with a history of gastroduodenal ulcers benefit from gastric protection if they take NSAIDs or antiplatelet therapy regularly. PPIs should also be continued in cases of refractory gastroesophageal reflux disease, Barrett’s esophagus, Zollinger-Ellison syndrome, and idiopathic chronic ulcer. However, these diagnoses cannot be reached without a full workup in symptomatic patients. Physician awareness and patient education are key to achieving the best outcome with the appropriate treatment.
Christopher Medrano is a family medicine resident.
