Discussing proton pump inhibitor deprescribing: the views of Danish GPs and older patients

Abstract

Background: Deprescribing of proton pump inhibitors (PPIs) can be considered in situations where the drug may no longer be necessary; however, this requires a careful discussion between patients and healthcare providers, often general practitioners (GPs). The aim of our study was to explore how GPs discuss PPI deprescribing with patients and compare that to how older patients would like to discuss this decision. Methods: We conducted a qualitative study using semi-structured interviews with GPs (n = 11) and patients aged ≥65 years who were taking PPIs (n = 4). Analysis of interviews was based on systematic text condensation. Results: We identified four main themes: (1) Reasons PPI deprescribing comes up, (2) Considering PPI deprescribing, (3) Discussion topics, and (4) Incorporating patient preferences into PPI deprescribing decisions. We found that PPI deprescribing often comes up during consultations for other problems or due to concern about medication burden in general. GPs discussed topics related to symptom control, such as the possibility of rebound symptoms, the need to taper PPIs, and what to do if symptoms returned. This aligned with what patients felt was important to discuss. Some GPs routinely incorporated patient preferences into decisions, whereas others did not. Conclusion: When discussing PPI deprescribing, the GPs in our study generally focused on topics related to symptom control. There was variability in how and if patient preferences were discussed. Greater focus may be needed on developing mechanisms to elicit and incorporate patient preferences into PPI deprescribing decisions. Future research could also explore more systematic approaches to reassess ongoing PPI use in an effort to curb unnecessary long-term use of PPIs.

Attitudes of older adults and their carers towards de‐prescribing: A systematic review

“…12,40 3.6.3 | Monitoring (n = 7) Older people were more willing to have a medication stopped if there was a monitoring process in place. 12,39,[46][47][48] For some this was the availability of blood tests to ensure certain parameters such as blood cholesterol, remained stable even after stopping the medication, whereas for others it was about considering this process as a trial with the possibility of going back on their medication should this be necessary. 39,47 Some preferred a weaning period before cessation of the medication and withdrawal of medication one at a time.…”

“…12,39,[46][47][48] For some this was the availability of blood tests to ensure certain parameters such as blood cholesterol, remained stable even after stopping the medication, whereas for others it was about considering this process as a trial with the possibility of going back on their medication should this be necessary. 39,47 Some preferred a weaning period before cessation of the medication and withdrawal of medication one at a time. 12,48 Those taking antidepressants expressed the tapering process would also be facilitated if at first prescription they are informed the length of treatment would be of a limited duration.…”

“…40 Our systematic review identified that some older adults and carers value the use of educational material that can help them initiate conversations and discussions about de-prescribing with the HCP, whereas others would prefer if the HCP initiated these conversations. 40,43,47 When conversations about de-prescribing arise some older adults and carers prefer for this to be framed in a positive way and the use of phrases such as 'Our bodies change over time and certain medicines may no longer be needed', seem to be more acceptable to older adults and their carers. 43 Carers also expressed that it was invaluable for medication effectiveness to be re-evaluated regularly and to see whether or not they were causing side effects which may not have been present previously.…”

Deprescribing proton pump inhibitors

“…Patients and prescribers may fear that symptoms will return when PPIs are discontinued. 21 Approximately 80% of patients with GORD remain symptom free after gradual dose tapering or discontination. 22,23 However, abrupt cessation can precipitate rebound acid hypersecretion in 10-50% of patients, which can be mistaken for a return of upper gastrointestinal symptoms, even in healthy adults without gastrointestinal disorders.…”

“…The possibility of rebound acid hypersecretion and preferences for a strategy to mitigate it should be discussed. 21 A useful phrase to gain patient acceptance is to talk about 'a trial of deprescribing', reassuring patients that the PPI can be restarted again if symptoms reoccur. It is important to create a personalised deprescribing plan and identify monitoring and support the patient may need.…”