Deprescribing interventions help curb PPI overutilization

Implementation of educational interventions targeted at deprescribing proton pump inhibitors (PPIs) has led to a sustained decrease in PPI use for more than 12 months at the institution level, according to a Singapore study.

“Cautious deprescribing of PPIs in eligible candidates was found to be safe with low recurrence rates of upper gastrointestinal (GI) events,” the researchers said.

Between 2016 and 2017, a series of deprescribing interventions was implemented to curb PPI overutilization in a Singapore tertiary hospital. The researchers disseminated an institutional PPI deprescribing guide by email and conducted educational roadshows to prescribers.

Interrupted time series analysis was performed to assess the effectiveness of the interventions over a 7-year period from 2013 to 2019. The researchers then ascertained the safety of PPI deprescribing by analysing the peptic ulcer disease incidence from 2015 to 2018 and by doing a retrospective chart review of 262 inpatients who were deprescribed PPIs.

A significant reduction in mean oral PPI utilization by 2,324.46 defined daily doses (DDD) per 1,000 prescriptions (95 percent confidence interval [CI], ‒3,542.66 to ‒1,106.26) per month was noted following the first intervention, followed by a month-to-month decrease of 302.61 DDD per 1,000 prescriptions per month (95 percent CI, ‒473.95 to ‒131.27). [Ann Acad Med Singap 2022;51:8-15]

A second targeted educational intervention was effective in sustaining the decline in the outpatient but not in the inpatient setting. No substantial changes were observed in the incidence of peptic ulcer disease. Moreover, majority of the patients (62.6 percent) remained deprescribed at 6 months in the retrospective chart review.

“Our retrospective chart review demonstrated a low rate of serious upper GI events in patients who were deprescribed,” the researchers said. “The majority of deprescribing was dose reduction or tapering, which tended to have higher success rates than abrupt discontinuation.” [Fam Pract 2014;31:625-630]

Confluence of factors

Of note, a gradual decline in oral PPI use had been observed from 2014 to 2016 prior to the first intervention. This could have been driven by a preceding nationwide campaign by the Pharmaceutical Society of Singapore from September to October 2015, which focused on PPIs as target for deprescribing at a healthcare system level. [www.pss.org.sg/sites/default/files/PW/PW15/1._polypharmacy-deprescribing_position_statement_final_240915.pdf]

“Beyond our educational interventions, the observed reduction in PPI utilization may have been contributed by a confluence of other factors such as environmental influence, supportive senior management, doctors’ and pharmacists’ involvement in driving rational prescribing within the institution, and increasing supportive literature over the years,” the researchers said. [Therap Adv Gastroenterol 2012;5:219-232; Clin Med Insights Gastroenterol 2012;5:65-76]

These findings from a single tertiary care centre have limited generalizability to primary care settings, but they provide enough evidence to support the use of educational interventions targeted at common perceived barriers to drug deprescribing.

“Further work is required to identify strategies that are sustainable in the long-term,” the researchers said. “Deprescribing should ideally be proactive and conducted by a multidisciplinary team with emphasis on patient communication, shared decision-making and intervention sustainability.” [Age Ageing 2021;50:1516-1519]