New data suggest that a pharmacy-based multicomponent intervention may help reduce proton pump inhibitor (PPI) prescribing, without increasing the risk of upper endoscopy or hospitalization for acid–peptic disease.
“This PPI deprescribing program was remarkably effective at reducing PPI use,” said lead study investigator Jacob E. Kurlander, MD, MS, of the Veterans Affairs (VA) Center for Clinical Management Research and Michigan Medicine. “Other than large-scale education campaigns, this was one of the largest ever PPI deprescribing interventions, and also one of the most effective.”
PPIs are frequently prescribed in the U.S., in part because they are effective and well tolerated. But concerns remain about unnecessary or inappropriate prescribing, partly because of questions about possible side effects.
The intervention took place in 2013 in a large network of VA facilities throughout multiple states, including most of Texas. By comparing trends in PPI use and health care utilization from these facilities to almost 4 million other veterans in the remainder of the Veterans Health Administration, Dr. Kurlander and colleagues were able to accurately quantify the effects of the intervention.
The intervention included:
- Restrictions on PPI refills that were not clearly indicated for long-term use.
- Cancellation of PPI prescriptions that were not filled in the previous six months.
- A quick-order prescription service for H2-receptor antagonist medications.
- Tracking reports to monitor high-dose PPI prescribing.
- Patient and clinician education on PPIs and their use.
The intervention resulted in a nearly 6% reduction in the number of veterans dispensed a PPI prescription in any six-month period.
“And it’s important to note that that’s an absolute reduction, not a relative reduction,” Dr. Kurlander added. “This means that about 1 in every 20 veterans was no longer using a PPI as a result of this intervention.”
The research team also found that the deprescribing intervention was not associated with an increased risk of upper GI bleeding or hospitalizations. However, they did find that there was a significant reduction in the use of PPIs in patients who are guideline-recommended to use them for the prevention of upper GI bleeding. This suggests room for improving the deprescribing process to ensure more appropriate use of PPIs for upper GI bleeding prevention. In their study, the rate of adherence to guidelines for upper GI bleeding prevention was roughly 50%.
“Deprescribing interventions need to take great care to ensure that only appropriate patients have their PPIs stopped since there’s the potential to actually cause harm,” said Dr. Kurlander. “Patients and doctors can get the impression that the problem with PPIs is just lots of overuse. But really, what’s needed is right-sizing, meaning many patients are on PPIs unnecessarily and can have them stopped, but at the same time, there’s many who would benefit from starting PPIs for bleeding prevention.”
Dr. Kurlander’s oral presentation of “A multicomponent intervention reduces proton pump inhibitor use without evidence of harm: A quasi-experimental study of over 4 million US veterans” took place on Sunday, May 23, at 1 p.m. EDT, as part of the AGA Clinical Science Plenary.