Encouraging appropriate use of proton pump inhibitors: existing initiatives and proposals for the future

ABSTRACT

Introduction

Proton pump inhibitors (PPIs) have revolutionized the management of acid-related disorders, representing today the mainstay treatment of these conditions. However, despite their large range of indications and usefulness, the remarkable expansion of their use in the last two decades cannot be explained by the increasing prevalence of acid-related diseases only. An inappropriate prescription for clinical conditions in which the pathogenetic role of acid has not been documented has been described, with the natural consequence of increasing the costs and the potential risk of iatrogenic harm due to adverse events and complications recently emerged.

Areas covered

In this review, we summarize current indications of PPIs administration, potential adverse events associated with their chronic utilization, and misuse of PPIs. Moreover, we describe existing and possible initiatives for improving the use of PPIs, and some proposals for the future.

Expert opinion

PPI deprescribing is the preferred and most effective approach to reduce the use of PPIs, rather than adopting sharp discontinuation, probably due to fewer withdrawal symptoms. Nonetheless, large knowledge gaps still exist in clinical practice regarding the optimal approach of PPI deprescribing in various clinical scenarios. Further prospective well-designed international studies are eagerly warranted to improve our perspectives on controlling global PPI inappropriate use.

KEYWORDS:

• Proton pump inhibitors
• GERD
• acid-suppressive therapy
• misuse
• PPI

Article highlights

• The prevalence of PPI use has been steadily increasing globally in the last 35 years causing relevant economic burden and, potentially, exposing patients to adverse events and complications.

• The increase in the use of PPIs is associated with inappropriate indication and also with unjustified prolonged treatment.

• Short-term PPI therapy is generally sufficient for the management of many acid-related disorders, while prolonged therapy could be limited to specific conditions such as prevention of gastric injury in high-risk patients taking non-steroidal anti-inflammatory drugs chronically, Zollinger Ellison Syndrome, severe erosive esophagitis, Barrett esophagus, and eosinophilic esophagitis.

• PPI deprescribing is possible in many cases and considered a challenging process that comprises physician education, patient preferences, professional societal guidelines, and governance intervention.

• Importantly, reevaluation of PPI indication should be assessed on a regular basis in clinical practice and deprescribing should be offered when possible.

• Large knowledge gaps still exist in clinical practice regarding the optimal approach of deprescribing in various clinical scenarios.

• Governance, scientific and professional organizational interventions, together with prospective well-designed international studies are all needed measures to improve PPI appropriate use in daily clinical practice.

Conflicts of interest

EV Savarino has served as speaker for AbbVie, AGPharma, Alfasigma, Dr Falk, EG Stada Group, Fresenius Kabi, Grifols, Janssen, Innovamedica, Malesci, Pfizer, Reckitt Benckiser, Sandoz, SILA, Sofar, Takeda, and Unifarco, has served as consultant for Alfasigma, Amgen, Biogen, Bristol-Myers Squibb, Celltrion, Diadema Farmaceutici, Dr. Falk, Fresenius Kabi, Janssen, Merck & Co, Reckitt Benckiser, Regeneron, Sanofi, Shire, SILA, Sofar, Synformulas GmbH, Takeda, and Unifarco and received research support from Pfizer, Reckitt Benckiser, SILA, Sofar, and Unifarco. The other authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.