Tips for weaning your patients off PPIs
From the July-August ACP Observer, copyright © 2004 by the American College of Physicians.
By Deborah Gesensway
NEW ORLEANS—While the long-term use of proton pump inhibitor-type drugs (PPIs) used for treating gastroesophageal reflux disease (GERD) appears to be safe, experts say that as many as half of all patients could be weaned off them.
Studies have demonstrated that nearly 60% of patients who discontinued daily PPIs stayed off them and were without symptoms one year later.
That was the message delivered by Joel E. Richter, FACP, chair of the department of gastroenterology and hepatology at the Cleveland Clinic Foundation, at his Annual Session presentation, "GERD for the Internist."
According to Dr. Richter, studies have demonstrated that nearly 60% of patients who discontinued daily PPIs stayed off them and were without symptoms one year later. Other studies have shown that patients who remain on the drugs can cut their dosages in half, going from twice daily therapy to one pill a day.
By tapering off—or reducing—their medications, Dr. Richter said, patients can reap both financial and health benefits.
Cost and safety concerns
In his presentation, Dr. Richter advised internists to keep GERD patients on PPIs from four to six months to provide complete relief and ensure healing of any inflammation from esophagitis.
Dr. Richter finds that many GERD patients can be tapered off proton pump inhibitors after four to six months.
How do you wean patients off of PPIs? Dr. Richter recommended first reducing dosages for between four to six weeks, then replacing the PPI with an H2-blocker, such as raniditine.
Tapering patients off PPIs has several advantages, Dr. Richter said. For one, cutting back on PPIs saves money. He pointed to one Veterans Administration study of step-down management of GERD that reported savings of $53,000 a year for the 71 patients enrolled in the study.
Even more importantly, stopping PPIs may be safer. Studies have shown that the five medicines in the PPI family are safe when used for 15 years. But beyond that, long-term effects really aren't known, said Dr. Richter. And if patients must stay on the medication to control their heartburn, that factor is usually apparent right away when they try to cut back.
"If they fail, they fail early," he said, "but you should try." He added that those failures usually occur with young patients who have severe heartburn.
For patients who develop a tolerance to H2-blockers, Dr. Richter advised telling them to use the medications only occasionally, such as when they need to control nocturnal intragastric acid breakthrough.
While that night-time breakthrough may annoy patients, Dr. Richter said those symptoms are a major reason PPIs appear to be safe over a long time: "They do not eliminate acid secretion," he said. "They just reduce the volume."
Coaching is key
When prescribing PPIs, primary care physicians can make mistakes, he added. Their biggest oversight? Not giving patients enough instructions on how and when to take the medications.
"There is a right way to use them," he said. The best time to take PPIs is 15 to 30 minutes before breakfast, he pointed out; patients who don't eat breakfast should take them before lunch. That's because it takes about 15 minutes for the medicine to be absorbed into patients' system.
Then you need to "wake up the acid-secreting pumps with food," he said. "It's not enough to just have coffee." If a patient's stomach remains empty after taking a PPI, efficacy is reduced 30%.
Physicians also need to understand that the different PPIs—from 15-year-old omeprazole (Prilosec) to three-year-old esomeprazole (Nexium)—appear to be equally effective. About one-fourth of all patients with GERD also have esophagitis and, contrary to drug company advertising, all PPIs basically work as well as the others to heal the esophagus.
"For most people," Dr. Richter pointed out, "you don't need the newest and best PPI." For patients with the uncommon form of GERD with severe esophagitis, however, he said that studies have found esomeprazole to be somewhat more effective.
If reflux does not improve with a PPI, the cause of the patient's symptoms is probably not GERD. Then, he said, "you need to rethink the disease."
While patients with GERD occasionally present with non-gastrointestinal symptoms-usually symptoms of the ear, nose and throat, such as cough or hoarseness, or the pulmonary symptoms of asthma or bronchitis-Dr. Richter said he finds the concern about non-GI symptoms of the disease to be somewhat overblown. However, the one group of patients he does believe should be checked for GERD are "difficult to manage asthmatics."
So far, he added, most studies on treating reflux laryngitis with either an H2-blocker or a PPI have not shown much difference between the medicine and placebo.
And although some GERD patients—particularly younger patients with no co-morbidities—would benefit from one of several available surgical treatments, Dr. Richter said internists should caution patients leaning toward surgery that the procedure probably won't be a permanent cure. Like all surgeries, the procedures have safety risks—and patients will probably need to go back on some form of anti-reflux medications in five to 10 years.
"It's not like getting a new valve for your car," he said, comparing surgery instead to a tune-up. "It wears out over time."
Dr. Richter also discussed the latest thinking about Barrett's esophagus. He recommended that internists stress to patients with Barrett's that their risk of developing esophageal cancer is very small, at worse only around 5%.
The bad news is that no tests are available to tell you which patients with Barrett's fall into that 5% category. Barrett's is most common in white men over age 50 who have a long history of GERD.
In addition, Dr. Richter said, some evidence suggests that the dysplasia of Barrett's esophagus can regress when treated with PPIs, but not with H2-blockers.
"People with Barrett's should be on aggressive PPI treatment," he said.
Evidence now shows that non-steroidal anti-inflammatory drugs and aspirin can also protect against esophageal cancer. Said Dr. Richter: "I give all my patients with Barrett's one low-dose aspirin a day."
Deborah Gesensway is a freelance health care writer living in Glenside, Pa.
The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP.
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