1. 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

2. 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
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
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