Moving away from the ‘Promo’, and more towards the ‘Clinical’….. Phew!
This is my take on deprescribing and potential considerations with potential actions in the case of a PPI. Enjoy…!
Deprescribing may be considered as the process by which inappropriate medicines are withdrawn or stopped with the intention of reducing “polypharmacy”. Naturally, the review process is favourable for the patient as the risk from medicines can be significantly reduced. There are several good examples of deprescribing out within the public domain, one such is proton pump inhibitors (PPIs) that are frequently prescribed for dyspepsia.
Considerations for a patient prescribed a PPI might include:
1. The provision of lifestyle advice to manage the dyspepsia (e.g. healthy eating, weight reduction, smoking cessation plus those foods that trigger the issue)
2. Reviewing current medication for possible causes of dyspepsia (e.g. calcium channel blockers, bisphosphonates, corticosteroids and NSAIDs)
3. Minimising the long-term prescribing of PPIs to reduce risks (e.g. Clostridium difficile, bone fractures, higher mortality in older patients, acute interstitial, hypomagnesaemia, vitamin B12 deficiency and rebound acid hypersecretion)
4. Providing annual reviews to those people in need of long-term management of dyspepsia
5. Considering a ‘step-down’ to the lowest effective dose for symptom control or prescribing on an ‘as needed’ basis over time
6. Be aware to those patients with a reduction in renal function, either initially or over time
7. Consider the ‘step-down’ management plan. If the PPI is to be withdrawn then OTC alginates or antacids may be purchased, if appropriate
8. Referral for those patients over 55 years, with weight loss, to a suitably qualified medical practitioner
Action points for patients receiving PPIs may include:
1. Prescribing a low acquisition cost PPI for the shortest possible duration
2. Consider histamine H2-receptor antagonist therapy (e.g. ranitidine) if the response to the PPI is inadequate. Point dependent on UK stock levels!
3. Formulation choice should be a factor in decision making. For example, in some regions dispersible tablets should be used only in patients with swallowing difficulties or with gastric tubes. In addition, requests for PPI liquid specials may need review ahead of supply
4. Those patients taking lansoprazole should leave at least half an hour before eating to achieve the best effect (i.e. the intake of food can slow the absorption rate of the drug and drop bioavailability by 50%).
5. If the patient currently taking clopidogrel, do not prescribe omeprazole or esomeprazole due to the potential for interaction.
Current NICE guidelines (i.e. NG56) indicate that when undertaking the deprescribing process, therapeutic agents should be stopped one at a time. However, there may be times a person-centred approach needs to be taken whereby decisions are based on the patient’s circumstance. For instance, for a patient who is terminally ill and towards the end stages of their life then several medicines may potentially be stopped at the same time except those providing some form of symptomatic relief. Conversely, a patient prescribed simvastatin may wish to stop the supply due to their beliefs about the medication. Professionals need to make their decisions based upon the best outcomes for the patient.
Clearly the process of deprescribing can be complex in nature and the practitioner must consider aspects including disease status, patient status, organ function, drug administration to the body alongside the wishes of the patient.
Further information / guidance on this subject can be found here: https://managingmeds.scot.nhs.uk/for-healthcare-professionals/7-steps/. This excellent, step-wise approach offers the professional with a framework to operate against. Structured guidance is key!
Deprescribing can lead to improved health outcomes for the patient and enable the efficient use of NHS resources over time. Consider it next time you practice as a healthcare professional.
