Proton pump inhibitors in clinical practice
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Proton Pump Inhibitors: Clinical Practice Patterns and Indications
Proton pump inhibitors (PPIs) are widely used for managing acid-related gastrointestinal diseases. They are most commonly prescribed for conditions such as gastroesophageal reflux disease (GERD), peptic ulcers, eradication of H. pylori (in combination with antibiotics), prevention of NSAID-induced ulcers, and as co-therapy in upper gastrointestinal bleeding and Zollinger-Ellison syndrome 256. Both gastroenterologists and primary care physicians frequently prescribe PPIs, but their prescribing patterns differ, especially regarding prevention of NSAID-induced ulcers and uncomplicated heartburn .
Overuse and Inappropriate Prescribing of PPIs
Despite clear evidence-based indications, PPIs are often overprescribed or used for longer durations than necessary. Common examples of inappropriate use include prescribing PPIs for patients without risk factors for ulcers, for stress ulcer prophylaxis outside of intensive care, or as an add-on to corticosteroid therapy without clear benefit 356. Clinical audits have shown that interventions and education can significantly reduce inappropriate PPI use in general practice . Overprescription not only increases healthcare costs but also exposes patients to unnecessary risks 56.
Safety Profile and Adverse Effects of PPIs
PPIs are generally considered safe, which has contributed to their widespread use. However, concerns have emerged about potential side effects, including infectious complications (such as Clostridium difficile infection and pneumonia), nutrient deficiencies (magnesium, iron, vitamin B12), kidney injury, bone fractures, and possible associations with dementia and gastric cancer 2810. Most studies indicate that the causal relationship between PPIs and these adverse events is weak, but it is still recommended to use the lowest effective dose for the shortest necessary duration 2810.
Deprescribing PPIs: Guidelines and Strategies
Given the prevalence of inappropriate long-term PPI use, deprescribing—systematically reducing or stopping PPIs when there is no clear indication—has become a key focus in clinical practice 24789. Effective deprescribing strategies include regular review of the indication for PPI therapy, involving patients in decision-making, and using clinical algorithms to guide the process 479. Gradual tapering, rather than abrupt discontinuation, is often recommended to minimize rebound acid hypersecretion, especially in patients with mild symptoms 49. However, patients with complicated GERD, Barrett’s esophagus, or high risk for gastrointestinal bleeding should generally not have their PPIs discontinued .
Best Practice Recommendations for PPI Use
Expert groups and clinical audits recommend that PPIs should only be prescribed when there is a valid, documented indication, and therapy should be regularly reviewed 237. Deprescribing should be considered for all patients without a clear need for ongoing therapy, and the process should be tailored to individual patient needs and preferences 2479. Education of both healthcare providers and patients is essential to ensure appropriate use and minimize unnecessary risks 46.
Conclusion
PPIs have transformed the management of acid-related diseases due to their efficacy and safety. However, their overuse and inappropriate prescribing remain significant issues in clinical practice. Regular review of indications, adherence to evidence-based guidelines, and thoughtful deprescribing are essential to optimize patient outcomes and reduce unnecessary risks and costs 23456789+1 MORE.
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