Outcome after Discontinuation of Proton Pump Inhibitors at a Residential Care Site: Quality Improvement Project

Increased prescribing of proton pump inhibitors (PPIs) in the past few decades can be attributed mainly to long-term use of this type of therapy. Recent evidence indicates signals of harm associated with long-term use of PPIs, such as increased risk of Clostridium difficile infection, recurrence of C. difficile infection, and fracture. A few studies have assessed the effectiveness of step-down management of patients receiving long-term PPI therapy in ambulatory care settings. However, it is unknown whether PPIs can be discontinued in older people without return of gastrointestinal symptoms.

To determine the proportion of residents receiving long-term PPI therapy who were able to discontinue the drug without experiencing gastrointestinal symptoms warranting recommencement of the PPI or initiation of a histamine-2 receptor antagonist.

The records of residents who had been taking a PPI for longer than 6 months at a single residential care site were audited by one pharmacist to determine the PPI indication. For residents who fit the criteria for discontinuation (no indication for long-term PPI therapy, not currently experiencing gastrointestinal symptoms, no previous trial of PPI discontinuation without success, and no anxiety when medications are discontinued), the pharmacist faxed a recommendation to discontinue PPI therapy without tapering to the physicians' offices. For cases in which the recommendation was accepted, 3 pharmacists followed the residents weekly for 8 weeks to assess whether gastrointestinal symptoms returned.

The pharmacist identified 28 residents who fit the criteria, and the recommendation to discontinue therapy was accepted for 27. At 8 weeks after the intervention, 19 (70%) of these residents were still asymptomatic and did not require re-initiation of medications to manage their gastrointestinal symptoms.

These results support discontinuation of long-term PPI therapy for older people who fit the criteria for discontinuation. The study provided limited evidence to support the use of tapering. However, tapering can be used to identify the lowest effective dose and may increase patient comfort with deprescribing. Further research is needed to determine the effects of and best approaches to PPI discontinuation in older populations.