Weaning Patients Off of PPIs

The aim of a prospective study published in 2015 was to assess the feasibility of a patient-centered deprescribing process in a population of adults with complex polypharmacy (Ann Pharmacother. 2015;49:29-38). The patient-centered deprescribing process consisted of five steps:

1. Collecting a comprehensive medication history;
2. Identifying potentially inappropriate medications;
3. Determining whether the medication could be discontinued;
4. Planning the withdrawal regimen, tapering where necessary; and
5. Providing monitoring, support, and documentation.

Fifty-seven PPI users were recruited; participants were 70 (± 14) years old and took 14 (± 6) medications. Indication for use was verified in 43 participants and judged as potentially inappropriate in 19; eight of those were suitable for trial withdrawal, and six consented. All six successfully discontinued or reduced their PPI use, which was sustained at six months out in four participants.

Barriers to Deprescribing

Although deprescribing has been successful in many studies, there are some barriers to successfully implementing this strategy in a clinical practice. Some physicians prefer to continue prescribing PPIs regardless of actual indications, and many patients who might do well without PPIs put pressure on physicians to keep prescribing them. The lack of clear weaning guidelines and the fear of withdrawal or rebound symptoms are key concerns for both. (Rebound acid hypersecretion following PPI discontinuation can lead to increased stomach acid production, beginning the cycle again.)

Reeve and colleagues found that although participants accepted the weaning protocol, the time required for accessing complete medical histories and assessing follow-up conditions made the process difficult to manage during regular medical consultations.

Patient lifestyle choices present one barrier to deprescription. “Patient lifestyle changes can affect LPR symptoms—eating late at night and coffee consumption, for instance. But adopting lifestyle modifications is difficult,” said Dr. O’Dell. “These modifications become an issue in how successful weaning will be. I think more patients would be able to come off of the medication if they were able to make and sustain lifestyle modifications.”

“In addition, as physicians we can get into a pattern where if patients are doing well, we prescribe the same medications, regardless of actual need; we don’t know that LPR really needs lifelong treatment,” she added. “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. I think it’s probably worthwhile to try to wean them off and see if the PPIs are what’s really helping to improve their symptoms.”