Proton Pump Inhibitor (PPI) Deprescribing Algorithm August 2018

Why is patient taking a PPI?

Indication still If unsur t if history of endoscopy, if ever hospitalized for bleeding ulcer or if taking because of chronic
unknown? NSAID use in past, if ever had heartburn or dyspepsia

• Mild to moderate esophagitis or • Peptic Ulcer Disease treated x 2-12 weeks (from NSAID; H. pylori ) • Barrett’s esophagus
• GERD treated x 4-8 weeks • Upper Gl symptoms without endoscopy; asymptomatic for 3 consecutive days • Chronic NSAID users with bleeding risk
(esophagitis healed, symptoms • ICU stress ulcer prophylaxis treated beyond ICU admission • Severe esophagitis
controlled) • Uncomplicated H. pylori treated x 2 weeks and asymptomatic • Documented history of bleeding GI ulcer

Recommend Deprescribing
Strong Recommendation (from Systematic Review and GRADE approach)

Decrease to lower dose (evidence suggests no increased risk in return of Continue PPI
symptoms compared to continuing higher dose), or Stop PPI or consult gastroenterologist if
Stop and use on-demand (daily until symptoms stop) (1/10 patients may
have return of symptoms)
considering deprescribing

Monitor at 4 and 12 weeks

If verbal: If non-verbal:
• Heartburn • Dyspepsia • Loss of appetite • Weight loss
• Regurgitation • Epigastric pain • Agitation

Use non-drug approaches Manage occasional symptoms If symptoms relapse:

• Avoid meals 2-3 hours before • Over-the-counter antacid, H2RA, PPI, alginate prn If symptoms persist x 3 – 7 days and
bedtime; elevate head of bed; (ie. Tums®, Rolaids®, Zantac®, Olex®, Gaviscon®) interfere with normal activity:
address if need for weight loss and • H2RA daily (weak recommendation – GRADE; 1/5 1) Test and treat for H. pylori
avoid dietary triggers patients may have symptoms return) 2) Consider return to previous dose

© Use freely, with credit to the authors. Not for commercial use. Do not modify or translate without permission.
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
Contact deprescribing@bruyere.org or visit deprescribing.org for more information.

Farrell
FarrellB,B,
Pottie K, Thompson
Pottie K, ThompsonW, Boghossian T, PizzolaT,L, Pizzola
W, Boghossian Rashid J, L,
Rojas-Fernandez
Rashid FJ, etC,al.
Walsh K, Welch V, Moayyedi
Deprescribing P. (2015).
proton pump inhibitors.
Evidence-based
Evidence-based clinical practice
clinical guideline
practice for deprescribing
guideline. Can Famproton pump2017;63:354-64
Physician inhibitors. Unpublished
(Eng),manuscript.
e253-65 (Fr).
 Proton Pump Inhibitor (PPI) Deprescribing Notes August 2018

PPI Availability Engaging patients and caregivers

Why is patient taking a PPI?
Indication still
PPI Standard dose
If unsure,
(healing) finddaily)*
(once
Low dose (maintenance)
out if history
(onceof
Patients
endoscopy, if ever hospitalized
daily) forand/or caregivers
bleeding ulcer ormay be more
if taking likelyoftochronic
because engage if they understand the
unknown?
Omeprazole
NSAID use in past, if ever had heartburn or dyspepsia rationale for deprescribing (risks of continued PPI use; long-term therapy may
20 mg+ 10 mg+ not be necessary), and the deprescribing process
(Losec ® ) - Capsule
Esomeprazole 20 a or 40 b mg 20 mg
(Nexium• ®Mild to moderate esophagitis or
) - Tablet • Peptic Ulcer Disease treated x 2-12 weeks (from NSAID; H. pylori) • Barrett’s esophagus
• GERD treated x 4-8 weeks
Lansoprazole • Upper Gl symptoms+ without endoscopy; asymptomatic for 3 consecutive days • Chronic NSAID users with bleeding risk
30 mg+ 15 mg
(Prevacid(esophagitis
®
) - Capsule healed, symptoms • admission
• ICU stress ulcer prophylaxis treated beyond ICU When an ongoing indication is unclear, the esophagitis
• Severe risk of side effects may
controlled) outweigh the chance of benefit
• Uncomplicated H. pylori treated x 2 weeks and asymptomatic • Documented history of bleeding GI ulcer
Dexlansoprazole 30 c or 60 d mg 30 mg
(Dexilant ® ) - Tablet • PPIs are associated with higher risk of fractures, C. difficile infections and
diarrhea, community-acquired pneumonia, vitamin B12 deficiency and
Recommend Deprescribing
Pantoprazole 40 mg 20 mg
(Tecta® , Pantoloc ® ) - Tablet hypomagnesemia

Rabeprazole 20 mg 10 mg • Common side effects include headache, nausea, diarrhea and rash
(Pariet ® ) - Tablet
Strong Recommendation (from Systematic Review and GRADE approach)

Decrease
Legend to lower dose (evidence suggests no increased risk in return of
Tapering doses
Continue PPI
symptoms compared to continuing higher dose), or Stop PPI or consult gastroenterologist if
Stop and use on-demand
a Non-erosive reflux disease
b Reflux esophagitis
(daily
* Standard
indicated
untilPPI
dose symptoms
in treatment
have
taken BIDstop)
only(1/10 patients may
of peptic ulcer
return of symptoms) •
considering deprescribing
No evidence that one tapering approach is better than another
caused by H. pylori ; PPI should generally
c Symptomatic non-erosive be stopped once eradication therapy • Lowering the PPI dose (for example, from twice daily to once daily, or
gastroesophageal reflux disease Monitor at 4 and 12 weeks
is complete unless risk factors warrant halving the dose, or taking every second day) OR stopping the PPI and
using it on-demand are equally recommended strong options
d Healing of erosive esophagitisIf verbal: continuing PPI (see guideline for details)
If non-verbal:
+ Can be sprinkled on food • Heartburn • Dyspepsia • Loss of appetite • Weight
• loss
Choose what is most convenient and acceptable to the patient
• Regurgitation • Epigastric pain • Agitation

Key
On-demand definition
GERD = gastroesophageal reflux disease
Use non-drug approaches SR = systematic review
Manage occasional symptoms If symptoms relapse:
• Avoid
NSAID = nonsteroidal meals 2-3 hours before
anti-inflammatory Over-the-counter antacid, H2RA,
GRADE = Grading of •Recommendations Daily intake
PPI, of a PPI
alginate prn for a period sufficient to achieve resolution
If symptoms persistofx the
3 – 7 days and
drugs bedtime; elevate head of bed; (ie. Tums®,
Assessment, Development individual’s reflux-related
Rolaids®, Zantac®, Olex®, Gaviscon®)
and Evaluation symptoms; following
interfere withresolution,
symptom the
normal activity:
address if need for weight loss and medication
• H2RA daily (weak recommendation – GRADE; 1/5 is discontinued until the individual’s symptoms recur, at which
1) Test and treat for H. pylori
H2RA = H2 receptoravoid
antagonist
dietary triggers point, medication is again taken daily until the symptoms resolve
patients may have symptoms return) 2) Consider return to previous dose

© Use freely, with credit to the authors. Not for commercial use. Do not modify or translate without permission.
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
Contact deprescribing@bruyere.org or visit deprescribing.org for more information.

Farrell B,B,
Farrell Pottie K, Thompson
Pottie W, Boghossian
K, Thompson T, PizzolaT,L,Pizzola
W, Boghossian Rashid J,L,
Rojas-Fernandez
Rashid FJ, etC,al.
Walsh K, Welch V, Moayyedi
Deprescribing P. (2015).
proton pump inhibitors.
Evidence-based clinical
Evidence-based practice
clinical guideline
practice for deprescribing
guideline. Can Fam proton pump2017;63:354-64
Physician inhibitors. Unpublished
(Eng),manuscript.
e253-65 (Fr).