The American Gastroenterological Association has issued new guidance for prescribing proton pump inhibitors (PPIs).
The 10 best practice recommendations are as follows
- For all patients on PPIs, primary care physicians should conduct a regular review of ongoing indications for use and document any indication for continued use.
- De-prescribing should be considered for any patients on chronic PPIs without a definitive indication.
- The majority of patients on twice-daily PPI dosing should be considered for once-daily step-down dosing.
- PPIs should not be discontinued for those with complicated GERD, including patients with a prior history of severe peptic structure, esophageal ulcers, or erosive esophagitis,
- A trial of PPI de-prescribing should also not be considered for those with eosinophilic esophagitis, idiopathic pulmonary fibrosis, or Barrett’s esophagus, where it has been shown to lower the risk of esophageal adenocarcinoma
- Physicians should use an evidence-based strategy assessing the risk of upper GI bleeding before a trial of de-prescribing — patients at risk may include those with a history of such bleeds and those on multiple antithrombotics, among others.
- If patients are at high risk for upper GI bleeds, such as those with the rare Zollinger-Ellison syndrome, PPIs should not be discontinued.
- Due to rebound acid hypersecretion, physicians should advise those discontinuing long-term (over 8 weeks) PPIs of the risk of transient upper GI symptoms.
- Abrupt discontinuation or dose tapering can be used to de-prescribe PPIs
- De-prescribing decisions should be solely based on the absence of a PPI use indication – not because of concerns over potential PPI-associated adverse events.