Ottawa, ON, May 15, 2017 — Millions of patients in Canada are taking a medicine known as a proton pump inhibitor (PPI). PPIs are commonly used to treat heartburn, indigestion and acid reflux. However, many patients continue taking these drugs when they may no longer need them. This unnecessary use puts patients at risk of side effects and contributes to unnecessary spending on drugs.

Now the first evidence-based deprescribing guideline to help doctors and other care providers reduce or discontinue potentially unnecessary PPI medicines has been published.

“Concern about the overuse of PPIs has been growing in recent years. Our guideline has been created to aid clinicians in evidence-based decision-making and the practical steps needed to reduce or discontinue PPI use in appropriate patients,” said Dr. Barbara Farrell. Dr. Farrell is a pharmacist and prescription drug expert who is a research scientist at the Bruyère Research Institute in Ottawa, and holds assistant professor positions in the Department of Family Medicine at the University of Ottawa and the School of Pharmacy at the University of Waterloo.

Farrell is the lead of an Ontario medical and pharmacist team who crafted the deprescribing guideline through a rigorous and systematic review of available research evidence. The comprehensive 11-page guideline includes an easy to use algorithm, dosage notes and extensive references.

Deprescribing proton pump inhibitors: Evidence-based clinical practice guideline

The guideline has been endorsed by seven national organizations including the Canadian Association of Gastroenterology, the Canadian Pharmacists Association, and the College of Family Physicians of Canada, which has just published the guidelines (PDF) in its journal, Canadian Family Physician.

“This guide will be very helpful for busy family doctors who want to help their patients reduce their use of proton-pump inhibitors,” notes Dr. Kevin Pottie, an Ottawa-based family physician and researcher who was one of the co-authors of the guideline. “Doctors learn how to prescribe drugs, but not always when or how to stop them. This evidence-based guideline is the first of its kind to help us deprescribe.”

The guideline notes that in 2012, PPIs were the fifth most commonly prescribed drug in Canada, with more than 11 million prescriptions dispensed, most commonly for gastro-esophageal reflux disease (GERD). Provincial drug programs spent about $250 million on PPI medications in 2013.

Studies show that most patients only need the drug for four to eight weeks, but research has found that around 50 percent of patients may stay on them longer than necessary, increasing the risk of associated harms. These include diarrhea, hip fractures, pneumonia, infection with C. difficile, impaired vitamin B12 absorption, and low levels of magnesium (hypomagnesemia).

The guideline clarifies which patients have health risks that necessitate their continuation of PPI medication and which patients can have their dose reduced or discontinued, with steps for how to do that safely. “This guideline is a tool to be used together with consideration of a patient’s personal and medical context,” said Farrell, who noted patients may not be used to discussions about how to stop medications. The authors have therefore also developed a patient pamphlet to help with these discussions and with handling heartburn or reflux symptoms should they recur. Patients wondering whether they still need their PPI should talk to their doctor or pharmacist about how the guideline applies to them; they should not simply stop a PPI on their own without medical advice, says Farrell.

Physicians who study the newly published guidelines will be eligible to earn credits towards their annual continuing medical education (CME) requirements, notes the College of Family Physicians of Canada.

The Deprescribing team is one of the research programs operating under the umbrella of OPEN — the Ontario Pharmacy Evidence Network — a consortium of academic scientists from six Ontario universities and research institutes who study the impact and effectiveness of medication management services.

“OPEN is a unique collaboration between leading experts from top Ontario universities who are working together to improve medication management in Canada,” said Dr. Lisa Dolovich, a member of the OPEN Executive and a professor at the Leslie Dan Faculty of Pharmacy, University of Toronto. “We feel certain this new guideline will help patients and their healthcare providers with better use of PPI medications.”

The Bruyère Research Institute supports investigators who contribute to a better, more responsive health care system that delivers the best care to patients and families. The Institute is a proud partner of Bruyère Continuing Care, the University of Ottawa and others and provides solutions to improve the health and health care of aging and vulnerable Canadians. The Institute’s research focuses primarily on evidence, health system evaluation, brain health, geriatrics and rehabilitation, and primary care.

• More information about OPEN
• More information about the deprescibing arm of OPEN
• More information about deprescribing in general

Deprescribing algorithm: Proton pump inhibitors

• Evidence-based deprescribing algorithm for proton pump inhibitors (PDF)
  An algorithm to help clinicians decide when and how to reduce proton pump inhibitors safely and how to monitor effect
• Algorithme de déprescription des inhibiteurs de la pompe à protons (PDF)
  Un algorithme d’aide à la décision clinique pour la réduction sécuritaire des inhibiteurs de la pompe à protons tout en assurant un suivi efficace
• Proton pump inhibitor deprescribing pamphlet (PDF)
  A pamphlet that accompanies the deprescribing algorithm for proton pump inhibitors to be used by doctors, nurse practitioners and pharmacists to guide deprescribing
• Un inhibiteur de la pompe à protons est-il toujours nécessaire? (PDF)

For more information or for interviews, please contact

Barbara Farrell BScPhm, PharmD, FCSHP
Scientist, Bruyere Research Institute
Assistant Professor, Department of Family Medicine, University of Ottawa
Adjunct Assistant Professor, School of Pharmacy, University of Waterloo
43 Bruyere St. Ottawa, ON  K1N 5C8
(613) 562-6262, extension 1315
bfarrell@bruyere.org