Results of an Intervention in an Academic Internal Medicine Clinic to Continue, Step-Down, or Discontinue Proton Pump Inhibitor Therapy Related to a Tennessee Medicaid Formulary Change

Abstract

indication for PPI therapy and acid suppression therapy was discontinued (discontinue therapy group), 40 (31.0%) met the TennCare PA criteria for continuation of PPI therapy (PA group), and 71 (55.0%) did not meet the TennCare PA criteria and were stepped down to a H2-blocker (step-down group). At the 8-month follow-up, acid suppression therapy was assessed in 68 patients (21 patients were lost to follow-up): 13 patients (19.1%) had resumed PPI therapy; 38 (55.9%) were using an H2-blocker; and 17 (25.0%) were not using acid suppression therapy. Telephone interviews were completed for 45 of the 75 patients in the step-down and discontinue therapy groups who did not receive an escalation in acid suppression therapy after the initial intervention (i.e., who did not make a change from H2-blocker therapy to PPI therapy or from no acid suppression therapy to H2-blocker or PPI therapy). Twenty-eight patients (62.2%) reported symptoms once per week or less; 14 patients (31.1%) reported symptoms more often than once weekly. Symptom control was unable to be determined in 3 patients (6.7%) because of incomplete information obtained from the patient during the interview. CONCLUSIONS: After a proactive collaboration between physicians and clinical pharmacists in response to changes in TennCare formulary criteria for PPIs, more than one-half of patients were stepped down to H2-blocker therapy, and 14% were discontinued from acid suppression therapy. Among the step-down or therapy discontinuation patients for whom data were available at the 8-month follow-up, 81% were still using either an H2-blocker or no acid suppressing therapy at all, and 19% had resumed PPI use.

Proton pump inhibitor prescribing patterns in the UK: a primary care database study

“…38 However, very few research studies have examined the extent to which the clinical guidelines 39 are being followed in the UK [14][15][16][17][18][19] . The aim of this study was to determine the prevalence of 40 PPI use and assess the practices employed to reduce PPI use in the general UK population. It 41 is anticipated that research of this nature will help to inform future attempts to moderate the 42 use of PPIs.…”

“…Previous studies [36][37][38][39] reported discontinuation rates that differed from those 236 identified in our study; however, these can be explained by variations in the study population 237 and the discontinuation strategies employed 38 . Reports regarding the outcomes of step-238 down therapy have been conflicting 40,41 . For example, one study reported that more than 239 half of the patients involved in the study remained asymptomatic after the step down 41 while 240 another reported that 19% of patients whose PPI therapy was stepped down experienced 241 relapsed symptoms and resumed PPI use 40 .…”

“…Reports regarding the outcomes of step-238 down therapy have been conflicting 40,41 . For example, one study reported that more than 239 half of the patients involved in the study remained asymptomatic after the step down 41 while 240 another reported that 19% of patients whose PPI therapy was stepped down experienced 241 relapsed symptoms and resumed PPI use 40 . In our study, 60% of the long-term PPI users 242 maintained lower doses for more than one year.…”

Impact of Clinical Pharmacists’ Recommendations on a Proton Pump Inhibitor Taper Protocol in an Ambulatory Care Practice

“…[23][24][25][26][27][28] Other studies have demonstrated the cost effectiveness and improvement in patient self-reported GERD symptoms with on-demand and intermittent PPI dosing. [29][30][31] Fewer data have been produced regarding the impact of clinical pharmacists, in an ambulatory care setting, on the reduction of chronic PPI use in patients without indication for long-term therapy.…”

“…Many previous studies utilized a follow-up period of 6-12 months. 23,24,26,27 Due to the fact that the follow-up period was shortened by 2 months, a greater portion of this period represented the actual taper process; thus, we postulated that the PPM count at follow-up may have been higher than what would have resulted if the follow-up period remained 5 months. Patients on the highest dose of a twice-daily PPI may have required upwards of 3 months before being transitioned to a H2RA.…”