PROTON PUMP INHIBITORS (PPI) DEPRESCRIBING PROTON PUMP INHIBITORS (PPI) In 2014, more than 59 million capsules of PPIs amounting to S$19 million were used in eight local institutions. CONTINUE Barrett’s esophagus Chronic NSAID users with bleeding risk Severe esophagitis Documented history of bleeding GI ulcer *Consult gastroenterologist if plan to deprescribe for the above patients APPROPRIATE INDICATIONS OF PPIs Zollinger-Ellison Syndrome Gastro-esophageal reflux disease* Peptic ulcer disease (PUD)* Helicobacter pylori eradication* Uninvestigated dyspepsia* Prevention of NSAID-induced ulcers in patients with risk factors#: Age > 65 years History of PUD or GI bleed Concurrent use of low dose aspirin, antiplatelets, anticoagulants or steroids Patients on dual antiplatelets with risk factors# * Use for less than 12 weeks # Risk factors should be constantly reviewed and PPIs deprescribed when risk factors resolve MONITORING Monitor patients at 4 and 12 weeks after deprescribing Signs and symptoms to look out for: Heartburn Regurgitation Dyspepsia Epigastric pain Agitation Weight loss Brought to you by: Pharmacy Week Committee 2016 CONTINUE Barrett’s esophagus Chronic NSAID users with bleeding risk Severe esophagitis Documented history of bleeding GI ulcer *Consult gastroenterologist if plan to deprescribe for the above patients APPROPRIATE INDICATIONS OF PPIs Zollinger-Ellison Syndrome Gastro-esophageal reflux disease* Peptic ulcer disease (PUD)* Helicobacter pylori eradication* Uninvestigated dyspepsia* Prevention of NSAID-induced ulcers in patients with risk factors#: Age > 65 years History of PUD or GI bleed Concurrent use of low dose aspirin, antiplatelets, anticoagulants or steroids Patients on dual antiplatelets with risk factors# * Use for less than 12 weeks # Risk factors should be constantly reviewed and PPIs deprescribed when risk factors resolve MONITORING Monitor patients at 4 and 12 weeks after deprescribing Signs and symptoms to look out for: Heartburn Regurgitation Dyspepsia Epigastric pain Agitation Weight loss Brought to you by: Pharmacy Week Committee 2016 CONTINUE Barrett’s esophagus Chronic NSAID users with bleeding risk Severe esophagitis Documented history of bleeding GI ulcer *Consult gastroenterologist if plan to deprescribe for the above patients APPROPRIATE INDICATIONS OF PPIs Zollinger-Ellison Syndrome Gastro-esophageal reflux disease* Peptic ulcer disease (PUD)* Helicobacter pylori eradication* Uninvestigated dyspepsia* Prevention of NSAID-induced ulcers in patients with risk factors#: Age > 65 years History of PUD or GI bleed Concurrent use of low dose aspirin, antiplatelets, anticoagulants or steroids Patients on dual antiplatelets with risk factors# * Use for less than 12 weeks # Risk factors should be constantly reviewed and PPIs deprescribed when risk factors resolve MONITORING Monitor patients at 4 and 12 weeks after deprescribing Signs and symptoms to look out for: Heartburn Regurgitation Dyspepsia Epigastric pain Agitation Weight loss Brought to you by: Pharmacy Week Committee 2016

ADVERSE EFFECTS OF PPIs STOP Clostridium difficile infection Community acquired pneumonia Increased risk of hip fractures Hypomagnesemia Dementia Chronic kidney disease After 2-12 weeks of PUD treatment (NSAID, H. pylori) On completion of H. pylori eradication ICU stress ulcer prophylaxis beyond ICU admission No indication* *If unsure, find out if there is a history of endoscopy, hospitalisation for bleeding ulcer, past chronic NSAID use or symptoms of heartburn or dyspepsia OVERVIEW OF DEPRESCRIBING Consider tapering to lowest effective dose Tapering options: 50% reduction BD to OD dosing PRN basis Choose what is most convenient and acceptable to the patient DECREASE DOSE OR SWITCH TO PRN Mild to moderate esophagitis GERD treated for 4-8 weeks, esophagitis healed and symptoms controlled Please scan QR code for more information on deprescribing and full list of references, or visit http://tinyurl.com/psspwhcp ADVERSE EFFECTS OF PPIs STOP Clostridium difficile infection Community acquired pneumonia Increased risk of hip fractures Hypomagnesemia Dementia Chronic kidney disease After 2-12 weeks of PUD treatment (NSAID, H. pylori) On completion of H. pylori eradication ICU stress ulcer prophylaxis beyond ICU admission No indication* *If unsure, find out if there is a history of endoscopy, hospitalisation for bleeding ulcer, past chronic NSAID use or symptoms of heartburn or dyspepsia OVERVIEW OF DEPRESCRIBING Consider tapering to lowest effective dose Tapering options: 50% reduction BD to OD dosing PRN basis Choose what is most convenient and acceptable to the patient DECREASE DOSE OR SWITCH TO PRN Mild to moderate esophagitis GERD treated for 4-8 weeks, esophagitis healed and symptoms controlled Please scan QR code for more information on deprescribing and full list of references, or visit http://tinyurl.com/psspwhcp ADVERSE EFFECTS OF PPIs STOP Clostridium difficile infection Community acquired pneumonia Increased risk of hip fractures Hypomagnesemia Dementia Chronic kidney disease After 2-12 weeks of PUD treatment (NSAID, H. pylori) On completion of H. pylori eradication ICU stress ulcer prophylaxis beyond ICU admission No indication* *If unsure, find out if there is a history of endoscopy, hospitalisation for bleeding ulcer, past chronic NSAID use or symptoms of heartburn or dyspepsia OVERVIEW OF DEPRESCRIBING Consider tapering to lowest effective dose Tapering options: 50% reduction BD to OD dosing PRN basis Choose what is most convenient and acceptable to the patient DECREASE DOSE OR SWITCH TO PRN Mild to moderate esophagitis GERD treated for 4-8 weeks, esophagitis healed and symptoms controlled Please scan QR code for more information on deprescribing and full list of references, or visit http://tinyurl.com/psspwhcp