Weaning Patients Off of PPIs

The term for weaning patients off of medication is “deprescribing,” a process that involves slowly withdrawing and stopping the medication. “Unfortunately, there really isn’t much information in terms of a ‘gold standard’ on what weaning protocols are the most effective,” said Karla O’Dell, MD, assistant professor of clinical otolaryngology at the University of Southern California Voice Center in Los Angeles. “Anecdotally, I think most use a de-escalation approach: If a patient is on a maximum dose twice a day, you would decrease the dose, then go from twice a day to once a day. Some physicians will transition patients from a PPI to an H2 blocker, and then stop completely.”

Because there is no cut-and-dried diagnostic for LPR, some physicians use a PPI as a sort of diagnostic test. But we don’t always think about getting patients back off of the PPI if that test fails. —Karla O’Dell, MD

Several studies have looked at ways to wean patients off of PPI therapy. Clark Rosen, MD, a professor of otolaryngology at the University of Pittsburgh School of Medicine in Pittsburgh, and his colleagues presented a retrospective review at the 2016 Triological Society meeting at the Combined Otolaryngology Spring Meetings (COSM) in Chicago. Thirty-seven patients with suspected LPR were instructed to wean from PPI using a standardized weaning protocol after successful treatment of their symptoms. Twenty-two of the 37 patients (59%) remained symptom free after deprescription. Fifteen patients (41%) had symptom recurrence, and 12 (32%) needed to go back on a PPI. The researchers also found that high body mass index was predictive of a failure to wean off the medication.

A recently published retrospective cohort examined 188 patients treated for LPR between April 1, 2011, and April 30, 2014, at the Queens Hospital Center Otolaryngology Clinic in New York City (Am J Otolaryngol. 2016;37:245-50). The clinic had instituted a standardized clinical protocol for LPR diagnosis and management in 2012, involving diagnosis using clinical judgment guided by the Reflux Symptom Index and Reflux Finding Score, treatment with PPIs, and weaning therapy after symptom resolution. This allowed the researchers to distinguish between patients who had been treated through the protocol and those who had not. The primary outcome measure was complete response to therapy and the secondary outcome measures were any response (complete or partial) and successful wean off PPI therapy.

The patients who were treated with the LPR protocol had higher rates of complete response, although there was no statistically significant difference in rates of any response (complete or partial) between the two groups, and were more likely to be successfully weaned off of PPI therapy than those who were not treated following the protocol. The 12-month wean rate was 52% for patients treated with the protocol versus 23% for patients treated without.