De-Prescribing Proton Pump Inhibitors in Patients With End Stage Kidney Disease: A Quality Improvement Project

Abstract

Background: Proton pump inhibitors (PPIs) are widely prescribed and may be associated with harm; hypomagnesemia and reduced effectiveness of calcium carbonate phosphate binders may be important in end-stage kidney disease (ESKD). Objectives: Our objectives included (1) discontinuing PPIs and H2 blockers and (2) assessing the impact on serum magnesium and markers of mineral metabolism. Design: Prospective cohort. Setting: Satellite hemodialysis unit of a tertiary care hospital. Patients: Incident and prevalent patients with ESKD treated with hemodialysis. Measurements: We assessed the impact of stopping PPI/H2 blockers in patients who did not have an absolute indication as per guidelines in the general population; serum magnesium, calcium, and phosphate were measured before and approximately 8 weeks later. Analysis of variance (ANOVA) test and Kruskal-Wallis was used to describe the population. Wilcoxon signed rank test for the paired change scores (from pre to post) Methods: The electronic medical record (EMR) was extensively searched for absolute indications for a PPI. Results were reviewed with the primary nephrology team before approaching patients about stopping the PPI. Basic demographic information and select medications were also collected. Results: Electronic medical records were reviewed for 179 patients, 74 had a PPI or H2 antagonist or both on their medication list (43%); 23 (31%) were assessed as appropriate. After primary team and patient review, 29 patients agreed to a trial of PPI withdrawal. Fourteen patients restarted their PPI, most for gastroesophageal reflux disease. Three patients had a GI bleed, 1 fatally. Serum calcium ( P = .17) and the dose of phosphate binders ( P = .075) did not change but serum phosphate increased (1.55 [0.29] to 1.85 [0.34] mmol/L; P = .0005). Serum magnesium also increased (1.01 [0.16] to 1.06 [0.14] mmol/L; P = .01). Limitations: Small patient numbers and observational nature of the study does not establish causation in this population at high risk to experience a gastrointestinal bleed. Conclusions: Our results suggest that PPI deprescribing as recommended in the general population may be associated with harm in patients with ESKD and requires further study. Trial Registration: Not registered.

Medication Deprescribing in Patients Receiving Hemodialysis: A Prospective Controlled Quality Improvement Study

“…GIBs were selected as a counterbalancing measure (an approach used in quality improvement studies) 35 because a prior, uncontrolled, observational study of deprescribing proton pump inhibitors (PPIs) in patients receiving dialysis found that 2 of 29 patients (7%) had a GIB within 2-4 weeks of having the PPI deprescribed. 36 Implementation barriers and facilitators were collected from semistructured interviews with nephrologists (reported separately).…”

Electronic Decision Support for Deprescribing in Patients on Hemodialysis: Clinical Research Protocol for a Prospective, Controlled, Quality Improvement Study

“…We will be reporting the number of gastrointestinal bleeds numerically, but we will not be powered to demonstrate a difference between intervention groups. 40 This is a single-center study, and to influence outcomes such as these likely requires more than 6000 patients (based on our previous study of MedSafer in the acute care setting). This study is also not randomized; we aim to minimize (but cannot eliminate), through statistical adjustment, obvious baseline differences in comorbidities between the control and intervention units.…”

Gastric Acid Suppression Therapy and Its Association with Peritoneal Dialysis–Associated Peritonitis in the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS)

“… 8 In another single-center interventional study stopping PPI and H2RA use, almost 50% restarted treatment because of gastroesophageal reflux, and 10% of the study participants had GI bleeding. 9 Clinicians should be aware of the possible higher risk of peritonitis among patients using GAS and regularly reassess treatment indications balanced against withdrawal risks.…”

“…7 Rates of GAS use among dialysis patients in two Canadian studies were similar to the Swedish study. 8,9 Reported adverse effects associated with GAS include pneumonia, Clostridium difficile infection, and spontaneous bacterial peritonitis in cirrhotic patients. 10 Previous studies suggested that GAS is a potential risk factor of PD-associated peritonitis.…”

“… 7 Rates of GAS use among dialysis patients in two Canadian studies were similar to the Swedish study. 8 , 9 …”