I often struggle with the question, “When can we discontinue a PPI?” It is rarely a black and white issue in the (mostly) geriatric population I work with. Here’s a scenario that might make things a little more black and white.
Patient 1:
She is 81 years old and has a history of GI bleeding. She has chronic atrial fibrillation and has had a history of multiple TIA’s and one CVA in the last year. She is not considered a candidate to go off warfarin therapy at this time. She also has a history of diabetes, and a previous MI for which she takes aspirin as well. This is definitely a case where it would be risky to discontinue a PPI for fear of GI bleed risk.
Patient 2:
Patient 2 is a 75 year old male who recently had an episode of dyspepsia. Omeprazole was started about 1-2 months ago. He encountered some pain issues (injured back) prior to the dyspepsia for which he was using ibuprofen. This back pain has now resolved and he seldom uses ibuprofen (less than 1 or 2 times per month). With the rare use of ibuprofen at this time and the omeprazole likely being added due to the frequent use of ibuprofen in previous months, this is an example where we can likely get more aggressive about discontinuing the PPI.
Hopefully, while not complete, these short scenarios give you some things to consider when looking at whether to discontinue a PPI or not.
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Make sure you taper a PPI if at all possible. They are/were referred to as “purple crack” for a reason.
Great topic! To further decrease bleed risk in patient #1, you could consider d/c’ing ASA as it should only be used concomitantly w/ warfarin in patients with mechanical heart valves. CHEST also recommends asa + warfarin in patients w/ recent coronary stents and ACS but there aren’t good data for this particular recommendation. Food for thought!
Thanks
Proton pump inhibitors are often started in critical care units for stress ulcer prophylaxis (mechanical ventilation, coagulopathy, etc.) and not discontinued upon transfer to the medical floor or step-down unit. Always keep in mind the appropriate indications for stress ulcer prophylaxis. Be sure to check back with ASHPs website, new SUP guidelines will hopefully be published soon.
Thanks!
The prescribing of or discontinuance of PPI is not a black and white scenario as made out here. Their use has to be weighed on the basis of harms and benifits in each individual case and no thumb rule exists for it. Their over prescription is a problem in the US but not so in the UK and other countries. A review says “There is NICE guidance on treatment of ulcers and heart burn which includes how to prescribe PPIs. PPIs can be used for non-ulcer dyspepsia but prolonged use of high doses should be avoided.” There is no evidence to prove their high doses have better effects as compared to low doses. Further fracture risk has to be considered while prescribing for elderly patients.
In the first instance (Patient 1) I presume all aspects were considered while prescribing PPI in low doses and hence think that it would not be wise to wean out the PPI.