Brief nurse-led educational support with recourse to alginate containing antacids for troublesome recurring symptoms can wean most patients off proton pump inhibitors (PPIs), finds industry funded research* published in the British Journal of General Practice Open.
The approach worked in three out of four patients who had been taking PPIs for two or more months, and has the added benefit of avoiding the potential health risks associated with these drugs as well as curbing prescription costs, say the researchers.
Dyspepsia guidelines recommend that patients treated with PPIs should step down to the lowest effective dose or return to self-care, but this can be difficult if and when symptoms return, with many patients ending up taking these drugs over the long-term.
PPIs were the third most commonly prescribed drug, accounting for 11% of the total in 2016.
The researchers wanted to find out if a nurse-led educational support programme plus rescue therapy for rebound symptoms might help patients reduce or stop their PPI use.
Some 6,249 patients from 26 general practices across the UK, who had been treated with PPIs for two or more consecutive months with an active repeat prescription, were invited to a 20-minute dyspepsia clinic appointment with a trained nurse adviser.
The patients were given verbal and written information about their condition, its causes, risk factors, alternative treatment options, and lifestyle factors. This included advice about identifying personal triggers and potential dietary risk factors, such as coffee, chocolate, and fatty foods, and advice about the impact of alcohol and smoking, if appropriate.
An action plan to reduce and/or stop their PPI use was agreed and alginate (Gaviscon Advance) supplied so that they could treat any rebound symptoms themselves at home.
After 12 months three out of four (75%) patients had reduced or completely stopped their use of PPIs: just over a third (35%) stopped; 5% reduced and then came off completely; and just under 35% reduced their use. Around one in 10 (just under 9%) went back to their original dose.
Overall, around 40% of patients stopped PPI treatment completely and 35% reduced their dose. These changes were achieved without any reported safety concerns and were maintained long-term: PPI reduction was maintained in 75% and 64% of patients at 12 and 24 months, respectively.
Across the 26 surgeries, PPI prescriptions fell from 89,915 to 45,880 and alginate prescriptions increased from 2,405 to 6,670.
An average of 1.7 bottles (500 ml each) of alginate were used for each patient who stepped down or off. Estimated annual prescription cost savings amounted to £31, 716.30 across all the participating surgeries.
“PPI overprescribing has been a recognised problem for more than a decade, but the number of PPI items dispensed in the UK continues to rise, doubling from 29 million in 2007 to 59 million in 2017,” write the researchers.
“The results of [this nurse led initiative] are a reminder that high-volume prescribing can be successfully reduced, and are particularly encouraging in light of the recent focus on empowering patients with evidence-based approaches to self-care,” they add.
“Greater guidance on rebound symptom management and broader use of a [dyspepsia therapy review and education programme] has the potential to significantly impact the risk of long-term harm to PPI-treated individuals,” they conclude.
*Coyle C, et al. Sustained proton pump inhibitor deprescribing among dyspeptic patients in general practice: a return to self-management through a programme of education and alginate rescue therapy. A prospective interventional study bjgpopen19X101651. DOI:10.3399/bjgpopen19X101651