Sustained proton pump inhibitor deprescribing among dyspeptic patients in general practice: a return to self-management through a programme of education and alginate rescue therapy. A prospective interventional study

Abstract

BackgroundDyspepsia guidelines recommend that patients treated with proton pump inhibitors (PPIs) should step down to the lowest effective dose or return to self-care, but rebound hyperacidity can make this difficult. Many patients continue on PPIs in the long term, which may lead to safety and financial implications.AimTo determine if a nurse-led educational support programme and rescue therapy for rebound symptoms can help patients achieve a sustained reduction in PPI use.Design & settingA prospective interventional study was conducted at 26 surgeries across the UK.MethodAdult patients, treated with PPIs for ≥2 consecutive months with an active repeat prescription, were invited to a 20-minute dyspepsia clinic appointment with a trained nurse adviser. An action plan to reduce and/or stop their PPI usage was agreed and alginate supplied for the self-management of rebound symptoms. After 12 months, PPI status was reviewed and prescribing cost savings calculated.ResultsAfter 12 months, 75.1% of 6249 eligible patients stepped down or off PPIs (35.3% stepped off; 5.0% stepped down then off; 34.8% stepped down only), while 8.7% of patients had reverted to their original PPI dose. PPI prescriptions fell from 89 915 to 45 880 and alginate prescriptions increased from 2405 to 6670. An average of 1.7 bottles (500 ml each) of alginate were used per patient who stepped down or off. Estimated annual cost-saving on prescriptions was £31 716.30.ConclusionA programme of education and short-term rebound symptom management helped the majority of patients to successfully step down or off PPIs, significantly reducing the potential risks associated with chronic therapy.

Understanding the Patient PPI Journey: Results of a Survey on PPI Treatment Initiation and Patient Experience

“…For example, a previous study conducted in the UK found that 3 out of 4 patients who entered the nurse-led Dyspepsia Therapy Review and Education Programme (DTREP) achieved a sustained reduction or complete discontinuation of PPIs using alginate as a short-term rescue therapy to overcome symptoms arising from rebound acid hypersecretion (RAHS) when coming off of PPIs.2 A 49% reduction in PPI prescribing over the 1-year review period was found, resulting in significant cost savings. 2 Relatively simple interventions such as the DTREP are 1 way in which to tackle the overuse of PPIs, as well as encouraging patients to gain a better understanding of their own care. Despite the National Institute for Health and Care (NICE) guidelines having clear recommendations on the appropriate prescribing of PPIs, UK practitioners have shown poor guideline adherence based on patient recall in this study, in line with previous findings showing little change in PPI prescribing patterns following the 2014 NICE guidelines.…”

“… 1 Since their clinical introduction during the 1980s, PPIs have become one of the most frequently prescribed drug classes worldwide. 2 - 4 Although they are indicated for the treatment of gastro-esophageal reflux disease (GORD), current guidelines recommend that patients with GORD, or un-investigated dyspepsia initially be offered lifestyle advice, such as healthy eating, weight reduction, and quitting smoking, before trying non-systemic over-the-counter (OTC) therapies such as antacids and alginates if symptoms are not adequately controlled. 5 , 6 In those with persistent symptoms despite lifestyle interventions and/or non-systemic therapies, full dose PPI treatment should be given for a course of 4 to 8 weeks 7 , 8 and then deprescribed in patients in whom symptoms resolve.…”

“… 14 Despite normalized long-term use, a majority of patients may be eligible to reduce or discontinue their PPI dose. 2 , 19 , 20 However, no attempt is made to deprescribe PPIs in 60% to 88% of long-term users, 21 , 22 even though patients are often willing to adjust their usage. 23 …”

The tapestry of reflux syndromes: translating new insight into clinical practice

“…Practical recommendations for when and how to reduce or discontinue PPI are now available 23 and a successful nurse-led PPI deprescribing programme in UK primary care has also recently been reported. 24 Non-PPI options for persistent symptoms Efficacy in healing high-grade oesophagitis is the only aspect of reflux disease management in which escalating the potency of PPI therapy (higher dose, twice-daily dosing, or more potent drug) has a demonstrable therapeutic gain. In contrast, there is no therapeutic gain with increased PPI dosage in patients whose reflux symptoms are not responding to standard-dose PPI.…”

Gastroesophageal reflux disease and alginates: diagnosis, treatment, prevention

“…Через 12 мес программы 75,1% из 6249 включенных пациентов отказались от ИПП, снизив тем самым потенциальные риски, связанные с хронической терапией. Снизилось и общее потребление медикаментов, что привело к снижению общих затрат: расчетная годовая экономия на рецептах составила 31 716,30 фунтов стерлингов [22].…”