Skip to content

Deprescribing PPIs

  • by

Geriatric pharmacist Dr. Kristina Niehoff explains how to safely deprescribe PPIs in older adults.

Hello my name is christina neehoff and i am the geriatric pharmacist on the acute care for the elderly unit at vanderbilt university medical center i have a passion for decreasing polypharmacy by deep prescribing potentially inappropriate medications in older adults today we will focus on one class of medications proton pump inhibitors as an example of a

Potentially inappropriate medication that can be a target for d prescribing older adults often n multiple chronic conditions for which they are prescribed multiple medications however not all medications that are prescribed are optimal the beers criteria is most is the most well-known list of potentially inappropriate medications which was recently updated

In 2015 in this most recent update proton pump inhibitors or ppis were added to this list when used for eight weeks or longer today we will discuss the mechanism of action of ppis long-term adverse effects and approaches to d prescribing this is a model illustrating the mechanism of action of a specific ppi omeprazole ppis are lipophilic weak bases which are

Permeable to the parietal cell membrane from the bloodstream they diffused there’s a cytoplasm become protonated the acidic environment of the secretory canaliculi since omeprazole is an irreversible inhibitor of the potassium hydrogen h ep ace pump which is an air it forms an irreversible covalent bond with this enzyme this inhibits hydrogen secretion from the

Parietal cell this process cannot be reversed until new pumps are made and the half-life of the hydrogen potassium pump is about 48 hours prescribing of anti secretory medications has substantially increased over the past decade indications for prescribing tp is includes mild-to-moderate esophagitis gastroesophageal reflux disease peptic ulcer disease upper gi

Symptoms stress ulcer prophylaxis h.pylori fair tohsaka sausages excusing barrett’s esophagus chronic inside users with bleeding risk severe esophagitis and documented history of a bleeding gie bolster pbis were historically thought to have few long-term side effects however emerging data suggest several long-term consequences of adverse effects from chronic

Ppi use which include nutrient deficiencies and infections we will discuss these in more detail some nutrients require gastric acidity to be absorbed which include magnesium calcium vitamin b12 and iron when the gastric ph is increased meaning the stomach becomes more basic these nutrients are not optimally absorbed as a result we see significant hypomagnesemia

Which often will not resolve with my museum repletion and requires this continuation of the ppi hypocalcemia has resulted in an increased fracture risk in both men and women with a 25-percent increased risk in overall fractures and forty-seven percent increase in spinal fractures in postmenopausal women calcium absorption can be overcome by using the calcium

Citrate formulation because the scituate salt is less affected by low gastric acidity other nutrients like vitamin b12 and iron can result in anemia over long periods of continuous use infections are the second long term quite effective has been observed ppi is increased ph which may allow for more bacterial growth resulting in changes of the respiratory and

Gastrointestinal microbiome this is evidenced by the increased incidence of pneumonia and clostridium difficile noted with chronic ppi use these long term side effects can be decreased by limiting pp i used to those who really need it data suggests that up to two-thirds of ppi users may be inappropriate and could be a target for discontinuation looking back to

Our indication slide the chronic conditions listed in the red box are reasons to continue taking a ppi so barrett’s esophagus barrett’s esophagus chronic inside users with bleeding risk severe esophagitis and documented history of a bleeding ulcer in the use cases you can consider consulting a gastroenterologist to discuss be prescribing all other indications

For ppis are fair game to attempt a discontinuation once you decide you want to do prescribe the ppi how do you attempt it well there are several medications that you can stop abruptly without fear of harm ppis are not on that list if a ppi is abruptly stopped a phenomenon known as rebound hypersecretion is observed in sixty to ninety percent of individual to

Take dpi’s for at least two to three months this is because pb is induced parietal cell proliferation which leads to a state of hyperacidity after discontinuation this rebound hyperacidity can create an uncomfortable situation for the patient and a subsequent dependence on continued ppi use rebound hypersecretion can occur in as little as eight weeks therefore

We must consider an alternative way of discontinuing the pp is a taper abrupt discontinuation has been shown to be effective at one year in fourteen to sixty-four percent of patients whereas a dose reduction has endpoints shown that thirty thirty to fifty percent of patients can tolerate a lower dose we recommend to decrease the ppi dose before decreasing the

Interval for example if a patient is on a members all 40 milligrams twice a day you would decrease to 20 milligrams twice a day before then decreasing to 20 milligrams once a day each step of the taper should take about two to for weeks once at the lowest possible once daily dose you can consider every other day dosing if breakthrough hypersecretion occurs you

Can recommend tums or for our older adults you can you want to recommend tums your older adults however in younger adults you consider using h2 antagonists we typically avoid h2 blockers and older adults is possible due to the negative effect on cognition this slide is showing you an example of a deep prescribing algorithm specifically for ppis this pdf can be

Found on d prescribing org along with several other d prescribing resources lastly i want to highlight the non-farm illogical treatments associated with with decreasing gerd symptoms such as voiding tobacco alcohol and acidic foods and beverages eating smaller more frequent meals elevating the head of the bed and weight loss thank you for listening to the

Presentation and best of luck with d prescribing pp is

Transcribed from video
Deprescribing PPIs By Geriatrics ACE Flix