Article Figures & Data
Figures
- Figure 1.
Deprescribing algorithm
Tables
- Table 1.
Appropriate prescribing of proton pump inhibitors: A) Evidence-based indications and duration for proton pump inhibitors, and B) indications for proton pump inhibitors based on gastrointestinal specialist advice.
A) MAIN SYMPTOMS EVIDENCE-BASED INDICATION HELICOBACTER PYLORI TESTING* INITIAL PRESCRIBING† LONG-TERM TREATMENT DEPRESCRIBING AND TOOLS Heartburn or regurgitation dominant Symptomatic GERD15 Not routinely SD: PPI once a day for 4 to 8 weeks, then reassess symptoms Some patients will require PPIs once a day or may need to step up to 2 times a day to maintain symptom control Yes—Figure 116 If symptoms are mild or worse for 2 days a week14 If response is equivocal give PPIs 2 times a day for 4 to 8 weeks, then decide on possible long-term maintenance treatment Epigastric pain or discomfort is dominant Dyspepsia17 Consider testing SD: PPI once a day for 4 to 8 weeks, then reassess symptoms Some patients will require PPIs once a day or may need to step up to 2 times a day to maintain symptom control Yes—Figure 116 Heartburn or regurgitation not dominant but may be present If response is equivocal give PPIs 2 times a day for 4 to 8 weeks, then decide on possible long-term maintenance treatment Chronic users of NSAIDs with other risk factors‡: anticoagulation and ASA, or DAPT NA Consider upper GI bleeding prophylaxis: PPI once a day Depends on indication and patient risk factor profile Yes, once medications requiring PPI prophylaxis are discontinued (Figure 116). No, if high-risk patient‡ B) EVIDENCE-BASED INDICATIONS H PYLORI TESTING* INITIAL PRESCRIBING† LONG-TERM TREATMENT DEPRESCRIBING OPPORTUNITY Erosive esophagitis (confirmed by gastroscopy) Not routinely SD PPI once a day for 4 to 8 weeks, then reassess symptoms Many patients will need to step up to PPI 2 times a day for symptom control Yes, if grade A
No, if ≥ grade BPeptic ulcer disease, duodenal or gastric ulcer Recommended: often done during diagnostic gastroscopy (consider ordering if not done) Uncomplicated ulcer: SD PPI once a day for 8 to 16 weeks Bleeding ulcer: PPI 2 times a day Yes, but not always. Bleeding ulcers need longer than 4 to 8 weeks of treatment No, not routinely. If considered, may require GI specialist Barrett esophagus No SD PPI 1 or 2 times a day Yes No, lifelong PPI Eosinophilic esophagitis No SD PPI once a day or 2 times a day Often yes No, not routinely. If considered, may require GI specialist Rare conditions Hypersecretory conditions like Zollinger-Ellison syndrome No SD PPI once a day or 2 times a day Yes, dose recommendation by GI specialist No, lifelong PPI Non-cardiac chest pain—presumed to be induced by GERD Not routinely. Requires gastroscopy, cardiac workup, and often esophageal motility testing, confirming there is no other cause explaining symptoms PPI 2 times a day Yes Yes, may require GI specialist (Figure 1)16 AHS—Alberta Health Services, ASA—acetylsalicylic acid, DAPT—dual antiplatelet therapy, GERD—gastroesophageal reflux disease, GI—gastrointestinal, NA—not applicable, NSAID—nonsteroidal anti-inflammatory drug, PPI—proton pump inhibitor, SD—standard dose.
↵* H pylori testing using H pylori stool antigen test or urea breath test. Treatment: antibiotics and PPI 2 times a day for 10 to 14 days. Many patients will still need long-term PPIs after H pylori treatment. For more information see the AHS H pylori pathway.18
↵† Initial prescribing: For SDs, PPIs are considered therapeutically equivalent: pantoprazole, 40 mg; esomeprazole, 40 mg; lansoprazole, 30 mg; dexlansoprazole, 30 mg; omeprazole, 20 mg; rabeprazole, 20 mg.
↵‡ Risk factors include age >65 y, taking anticoagulants, previous GI bleed, and upper GI symptoms. Reproduced with permission from Choosing Wisely Canada.16
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