Missed opportunities for attempts at de-escalation of proton pump inhibitor therapy

Introduction: Proton pump inhibitors (PPI) are amongst some of the most widely prescribed classes of medication in the United States. While long term treatment is appropriate in certain situations, attempts to should be made to reduce, or discontinue their use in many patients. Methods: A retrospective chart review of patients with a PPI listed as a current medication seen by a faculty gastroenterologist at an urban university medical center over a 12-month period was conducted. Data was collected to determine the indication for PPI use, reason for clinic visit, and whether or not there was a documented discussion of de-escalation of PPI therapy. De-escalation was defined as attempts at reduction in dose, reduction in frequency, or complete discontinuation, of the PPI. Patients prescribed PPI’s for Barrett’s esophagus, Helicobacter pylori infection, and gastrointestinal bleeding were excluded. A Microsoft Excel database maintaining subject confidentiality was used. Statistical analysis performed via two-tailed Fisher’s Exact Test, p\u3c0.05. Results: A total of 600 charts were initially reviewed, of which, 324 were included in the analysis. Of the 324 patients , 141 patients were prescribed a PPI by a gastroenterologist. 72 out of 141 were seen for GERD, and 69 seen for non-GERD reasons. 29 patients (40%) seen for GERD had documented discussions of de-escalation, compared to 12 (17%) of patients being seen for non-GERD reasons. A missed opportunity exists for attempts at de-escalation in patients who are prescribed a PPI by a gastroenterologist, yet being seen for a chief complaint unrelated to GERD (p = 0.0031). Discussion: Proton pump inhibitors are amongst the most commonly prescribed medications in the United States. There is evidence to suggest that patients with uncomplicated GERD who have obtained symptomatic relief with PPIs, should be able to successfully de-escalate their therapy. Our data show that when a gastroenterologist is the prescriber of a patient’s PPI, and the patient is being seen for a GERD related chief complaint, the likelihood of a documented de-escalation discussion is much greater than compared to when a patient is presenting for a non-GERD related chief complaint (40% vs 17%, p = 0.0031). While PPI’s are quite safe, and overall, well tolerated, nevertheless, their continued use in a patient should be re-evaluated periodically. There appear to be missed opportunities to for attempts at de-escalation of PPI during non-GERD related visits