deprescribing proton pump inhibitors
TRANSCRIPT
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Deprescribing Proton Pump Inhibitors
Colleen Donder, BSc (Pharm), ACPRKnowledge Mobilization OfficeCADTH
Kelda Newport, B.Sc.(Pharm), R.Ph.Project CoordinatorSaferMedsNL
Disclosures
No relevant commercial relationships or conflicts of interest to disclose
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Disclosures
CADTH is funded by federal, provincial, and territorial ministries of health.
• Application fees for three programs:
• CADTH Common Drug Review (CDR)
• CADTH pan-Canadian Oncology Drug Review (pCODR)
• CADTH Scientific Advice
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CADTH: Canadian Agency for Drugs and Technologies in Health
Kathleen Kulyk: Saskatchewan Liaison [email protected]
• Medical Devices and related Equipment Purchases
• Pharmacologic Agents• Surgical Procedures• Non‐surgical Procedures or
Approaches to Treatment• Vaccines and Other Preventive
Interventions
SaferMedsNL
• Health care leaders
• Clinicians
• Decision-makers
• Researchers
• Patient advocates
Tannenbaum et al. Can J Aging 2017
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SaferMedsNL
Goals
• Decrease the use of potentially harmful medications in NL
• Increase awareness of safer alternatives to medications and how to access them
Learning Objectives
• Recognize reasons for deprescribing and understand how it improves patient care
• Be familiar with evidenced-tools available to support pharmacists with the deprescribing proton pump inhibitors
• Recognize the role of pharmacists in deprescribing
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Polypharmacy in Canada
How many Canadians (≥65yrs) consume:
• ≥5 medications?
• ≥10 medications?
(CIHI 2018)
Polypharmacy in NL
How many seniors (≥65yrs) consume:
• ≥5 medications?
• ≥10 medications?
(CIHI 2018)
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Harms of polypharmacy
• Drug-drug and drug-disease interactions
• Non-adherence
• Geriatric syndromes
• Functional decline
• Cognitive impairment
• Urinary incontinence• Potentially inappropriate medication use• Under-prescribing of indicated medications
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Risk of drug-drug interactions
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Low risk
2 5-7 8-10
4-fold greater risk
8-fold greater risk
Number of medicationsJohnell, K., et al. Drug Safety; 2007; 30 (10): 911-918
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Provincial comparisons
• Benzodiazepines2nd highest use
• Benzodiazepines2nd highest use
Provincial comparisons
• Opioids highest use • Opioids highest use • PPIs highest use • PPIs highest use
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So what’s the cost?
• How much does Canada spend on inappropriate medications for seniors?
$419 million
• What is the “health system cost” of inappropriate medications in Canada?
$1.4 billionMorgan SG, et al. CMAJ Open 2016;4:E346‐51.
What’s the cost?
Newfoundland and Labrador spends:
$4.3 million on PPIs
$5.0 million on Sedative/Hypnotics
$3.4 million on Opioids
Associated costs unknown
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CIHI 2018
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What is deprescribing?
“Deprescribing is the process of withdrawal of an inappropriate
medication, supervised by a health care professional with the goal of managing
polypharmacy and improving outcomes.”
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Reeve, Emily et al. 2015
Do patients want to deprescribe?
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Sirois C, et al. Res Social Adm Pharm 2017;13:864‐70
71%
29%
Yes
No
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EMPOWER Trial
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EMPOWER Trial
• Patient education tool on benzodiazepines
• Cessation of benzodiazepine use
• Patients who received the education tool• 27% discontinued benzodiazepines
• 11% reduced the dose after 6 months
JAMA Intern Med. 2014 Jun;174(6):890‐8.
D-PRESCRIBE Trial
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D-PRESCRIBE Trial
PPIs Work!
• Dexlansoprazole
• Esomeprazole
• Lansoprazole
• Omeprazole
• Pantoprazole
• Rabeprazole
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Short-Term PPI Use
• Heartburn/Dyspepsia – 14 days
• GERD – 8 weeks
• Gastric & Duodenal Ulcers - 4-8 weeks
• H. Pylori – 2 weeks
• Stress Ulcer Prophylaxis – ICU
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Long-Term PPI Therapy
• Severe/Erosive Esophagitis
• Zollinger-Ellison Syndrome
• Chronic NSAID users with bleeding risk
• Documented history of bleeding GI Ulcer
• Barrett’s Esophagus
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Are PPIs harmful?
• Vitamin B12 and magnesium deficiency
• Fractures
• Pneumonia
• Clostridium difficile infection
• Renal Complications
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Schoenfeld, Adam Jacob and Deborah Grady. "Adverse Effects Associated with Proton Pump Inhibitors adverse Effects Associated with Proton Pump Inhibitors editorial." JAMA Internal Medicine, vol. 176, no. 2, 2016, pp. 172‐174, doi:10.1001/jamainternmed.2015.7927.
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Why PPIs?
• Over-use
• No current indication
• Adverse Effects
• Cost
• Potential for change
Canadian Pharmacists Association, Choosing Wisely Canada
“Don’t renew long-term proton pump inhibitor (PPI) therapy for gastrointestinal symptoms without an attempt to stop or reduce (taper) therapy at least once per
year for most patients.”
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Canadian Deprescribing Network (CaDeN)
“Inclusion of a pharmacist within the interdisciplinary team has been shown to
reduce unnecessary PPI use and can facilitate patient education, dose
changes, monitoring, and alerting the prescriber of ongoing symptoms.”
Can Fam Physician. 2017 May;63(5):354-364
Deprescribing
Where to start!?
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Deprescribing in 3 easy steps
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2
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IDENTIFY which drugs to deprescribe
Use EVIDENCE-BASED deprescribing
guidelines and algorithms
ENGAGE your patients and other
health care providers using effective
communication tools and techniques
Deprescribing approach
• Indication
• Effectiveness
• Side effects/harms
• Drug interactions
• Polypharmacy/pill burden
• Costs
• Patient and family values
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PPI Deprescribing
Where to start!?
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What’s next?
• Shared decision making
• What does the patient think about their PPI prescription?
• Are they open to consider stopping it?
Shared decision making process
Patient
PharmacistPrescriber
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Communication with prescriber
Community‐dwelling adults
Primary‐Care,
Doctors
Community Pharmacists
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Approaches for Deprescribing PPIs
• Reduce the dose then stop
• Stop and use PPI as needed
• Switch to H2RA daily
• Use OTC H2RA, antacids or alginates
• Recommend non-drug approaches
Non-Drug Approaches
• Elevating head of bed six inches
• Avoiding meals 2-3 hours before bedtime
• Weight loss, if appropriate
• Smoking Cessation
• Eat smaller meals
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Rebound Symptoms
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Up to 50% of patients who have been on long‐term PPIs may experience short‐term rebound symptoms following abrupt PPI withdrawal
Farrell, Barbara, et al. 2017
Symptom management plan
• As needed:
• Proton pump inhibitor
• Antacids
• H2RA
• Alginate
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Monitoring
• 4 weeks- assess symptom control
• 12 weeks- assess symptoms, frequency of on-demand use, need for further investigation or change back to regimen
• Patient can report as needed
Implementing deprescribing
1. Identifying the patient
2. Conversation with patient
3. Conversation with physician (if required)
4. Follow up
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What can Pharmacists do?
• Engage patients • Complete Pharmaceutical Opinion• Follow-up• Plan an “exit” strategy • Work collaboratively• Share consistent messaging• Partner with community champions • Order FREE Deprescribing Resources!!!!
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Free Evidenced-Based Patient Tools!!
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www.SaferMedsNL.ca
What can the public do?
• Become informed
• Talk to their doctor, pharmacist or nurse
• Spread the word about deprescribing
Ask questions, stay informed, be proactive,
and participate in making informed choices!
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What’s happening now?
• VOCM Banner Ads
• Moving Media Displays
• Saltwater Network News Ad
• Coffee News Ad
• Twin Rink Board Ad
• MetroBus Back of the bus Ad
• Eastern Health Media Displays
• YouTube Video
• Social Media
• NTV PSA
• Custom Content for the Telegram
• Good News Stories
• Community Outreach
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What’s Next?
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Keep in touch!
SaferMedsNL.ca
Kelda Newport: [email protected]
@SaferMedsNL
@SaferMedsNL
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Acknowledgements
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References
1. Farrell B, Pottie K, Thompson W, et al. Deprescribing proton pump inhibitors: Evidence-based clinical practice guideline. Can Fam Physician. 2017 May;63(5):354-364.
2. Canadian Deprescribing Network 2017 Annual Report https://static1.squarespace.com/static/5836f01fe6f2e1fa62c11f08/t/5a300de08165f55070242b6f/1513098731414/Annual+report+design+2017_FINAL_web.pdf
3. Waddleton D, Kelly D, Thompson R, Abbott J. An overview of a provincial appropriateness of care initiative: a provincial collaborative supporting appropriate, affordable, and accessible care. National Health Leadership Conference. June 5, 2018. [accessed Nov 29, 2018] http://www.nhlc-cnls.ca/2018-presentations/
4. Canadian Pharmacists Association. Six Things Pharmacists and Patients Should Question. November 2017. [accessed November 8, 2018] https://choosingwiselycanada.org/pharmacist
5. Tannenbaum C, Martin P, Tamblyn R, Benedetti A, Ahmed S. Reduction of inappropriate benzodiazepine prescriptions among older adults through direct patient education: the EMPOWER cluster randomized trial. JAMA Intern Med. 2014 Jun;174(6):890-8.
6. Martin P, Tamblyn R, Benedetti A, Ahmed S, Tannenbaum C. Effect of a Pharmacist-Led Educational Intervention on Inappropriate Medication Prescriptions in Older Adults: The D-PRESCRIBE Randomized Clinical Trial. JAMA. 2018 Nov 13;320(18):1889-1898.
7. Proton Pump Inhibitor Quick Reference Prescribing Aid. CADTH. Tool. February 3, 2016. [accessed December 3, 2018] https://cadth.ca/proton-pump-inhibitor-quick-reference-prescribing-aid
8. Proton Pump Inhibitor Therapy. CADTH. Optimal Use Report. August 29, 2010. [accessed November 27, 2018] https://www.cadth.ca/proton-pump-inhibitor-therapy
9. Proton Pump Inhibitors (PPIs) and Clostridium difficile Infection (CDI): What does the evidence say? CADTH. Tool. February 3, 2016. [accessed November 9, 2018] https://www.cadth.ca/sites/default/files/pdf/ppi_cdiff_bundle_en.pdf
10. Clopidogrel and Proton Pump Inhibitor Use: A Review of the Evidence on Safety. CADTH. Summary with Critical Appraisal. March 14, 2017. [accessed November 9, 2018] https://www.cadth.ca/clopidogrel-and-proton-pump-inhibitor-use-review-evidence-safety
11. NLPDP Coverage Status Table November 2018. [accessed November 8, 2018] https://www.health.gov.nl.ca/health/prescription/coverage_status_table.pdf
12. Alternatives to Proton Pump Inhibitors. CADTH. Tool. November 19, 2018. [accessed November 19, 2018] https://www.cadth.ca/tools/alternatives-proton-pump-inhibitors