1. Can Proton Pump Inhibitor Deprescribing be Undertaken in a Scottish Community Pharmacy Setting? A Feasibility Study.
Andrew Christopherson1,2, Alison H Thomson2, Anne Thomson1
¹ Strathclyde Institute of Pharmacy & Biomedical Sciences (SIPBS), University of Strathclyde ² Pharmacy & Prescribing Support Unit, NHS Greater Glasgow & Clyde
Objectives: The study aimed to test the feasibility of a larger research project to examine whether the deprescribing (stopping or reducing the dose) of Proton Pump Inhibitors (PPIs) can be successfully undertaken in a community pharmacy setting by a community pharmacist working in conjunction with a patient’s GP practice.
Indication still unknown?
Mild to moderate oesophagitis or
GORD treated for 4-8 weeks (oesophagitis healed, symptoms controlled)
Peptic Ulcer Disease treated for 2-12 weeks (from NSAID, H.pylori)
Upper GI symptoms without endoscopy; asymptomatic for 3 consecutive days
Uncomplicated H.pylori treated for 2 weeks and asymptomatic
Barrett’s oesophagus
Chronic NSAID users with bleeding risk
Severe oesophagitis
Documented history of bleeding GI ulcer
Zollinger-Ellison syndrome
Stop
PPI
Continue
Monitor at 4 and 8 weeks
Heartburn, Regurgitation, Dyspepsia, Epigastric Pain, Weight Loss, Loss of Appetite, Agitation
Proton Pump Inhibitor (PPI) Deprescribing Algorithm
Use non-drug approaches: avoid meals 2-3 hours before bedtime, elevate head of bed, consider weight loss and avoid dietary triggers
Manage occasional symptoms: OTC antacid, H2RA or alginate PRN
If symptoms relapse , persist for 3-7 days and interfere with normal activity:
Consider return to previous dose
Consider referral to GP for testing for H.pylori
Decrease to a lower dose or
Stop and use on-demand
Recommend Deprescribing
Why is the patient taking a PPI?
If unsure, ask the patient if they have ever: had an endoscopy; been hospitalised for a bleeding ulcer; had chronic treatment with an NSAID; had heartburn or dyspepsia
Methods: A PPI deprescribing algorithm (figure 1) was adapted and a PPI deprescribing educational session was developed for community pharmacists.
The deprescribing process was tested with five patients prescribed a PPI in a pilot community pharmacy and the process was modified following feedback from the pharmacist and patients.
Nineteen patients prescribed a PPI were recruited in a second community pharmacy and the pharmacist undertook interventions recommending that either:
The patient continued their PPI.
Reduced their PPI dose.
Stopped their PPI completely.
Twenty patients prescribed a PPI who did not receive an intervention from a pharmacist were recruited to the control arm. All patients were monitored and followed up over a 4-week period. The data was collated and statistical analysis applied.
Key Findings: After 4 weeks, the mean PPI defined daily dose (DDD) had decreased in the intervention arm from 1.53 (SD 0.03) to 1.15 (SD 0.37) and from 1.20 (SD 0.41) to 1.15 (SD 0.37) in the control arm. Overall, there was a higher reduction rate in the intervention arm compared to the control arm.
33.3% (n = 6) of patients in the intervention arm had a reduced PPI DDD after 4 weeks compared to 5.0% (n = 1) in the control arm. The Fisher Exact Test gave a statistical value of which is significant at p<0.05.
Twelve patients declined to take part in the study, with 7 patients citing lack of time, 2 patients wishing to discuss the PPI deprescribing with their GP first, and 1 patient stating that they felt a community pharmacy was not a suitable location to discuss stopping or reducing medicines. Two patients declined giving no reason.
Figure 1: Proton Pump Inhibitor Deprescribing Algorithm
Conclusions This feasibility study shows that community pharmacists can successfully deprescribe PPIs when working in conjunction with GP practices and lays the groundwork for a larger scale study.
Acknowledgements
Lisa Duncan and Sarah Johnson for collecting the data.
Bruyère Research Institute (University of Ottawa) for their kind permission to use and adapt the PPI deprescribing algorithm in this study